Medicare NPI Denial Changes May 1st

April 15, 2013

Medicare is moving to forward with their denials of incomplete claims. In phase one of this current missive they issued a warning stating the claims failed to meet NPI requirements.  In phase two these claims will be denied.  What this means is simply this:  Ordering and referring MDs must have an enrollment record with Medicare and their NPI and legal name must be posted on the claim. You must use the individuals ordering providers NPI not their group NPI. The following messages will be on the claims:

  • N264 Missing/incomplete/invalid ordering physician provider name
  • N265 Missing/incomplete/invalid ordering physician primary identifier

Again this is another reason to have a solid denial report from your billing agent and it is important for them to actually work this denial report.  This is another reason why your practice management firm should review these denial reports each and every month.

California Introduces a Bill to Keep Pathologists Forefront in ACOs

California is proposing a bill that would mandate that each ACO create a Clinical Laboratory Advisory Committee and that this committee include a physician who is the director of the clinical laboratory providing services to the ACO.  This keeps pathologists and their efforts directly involved in the ACO process. This is called State Bill 264 in California.  What is your state doing?

New HIPPA Rules Affect Patient Billing

A new rule goes into effect this week that can change your self-pay billing in a very unique way.  As  of March 26th. Consider this a patient who pays out of pocket can now request that their insurance NOT be billed.  The biller has to comply with this request.  If you do not comply with this request it is not a HIPPA violation.

Independent Labs Fighting Medicare to Get Paid.

If an independent labs bills an encounter on the same dote of services as the patient has an outpatient encounter they are not getting paid.  Several labs have contacted Medicaid about this issue and are fighting the battle to get paid for these services.  It seems that CMS has erroneously tied this payment to the TC Grandfather Clause as part of their hospital bundling edits.  The only real recourse at this time is to appeal each claim on an individual basis.

Sequester Payment Changes

Please note the sequester cuts do not actually affect the CMS fee schedule only the actual amount paid.  Therefore the payment amount and the fee schedule amount will differ.  Also the decreased amount will be taken after the deductible and co-pay are taken therefore the patient will actually have a larger co-pay and deductible.

Credit Card Numbers in-house

Many physicians are now choosing to gather credit card information upfront and requesting permission to put the patient balance on these cards.  This has some compliance and legal issues, for example are your employees bonded? This is an excellent way to get that pesky co-pay or deductible paid in full.

Tricare

It seems Tricare wants all claims submitted with a Department of Defense identification number yet has not given these numbers to all their members.  Therefore your claims may be denied if you submit them with the new Department of Defense number until all cards are distributed.   You will still need to request Sponsor’s SSN.

Value Based Payment Modifier (VBPM)

The Patient Protection and Affordable Care Act (ACA) required that Medicare (CMS) have guidelines in place for a value based payment.  This new modifier will be based on the quality and the cost of care to patients. It will be rolled out to select physicians and then expanded to all physicians on 2017. Your VBPM will be tied to your PQRS data.

It is imagined that this VBPM will be tied to your payment and can affect your payments in a positive or negative way depending on your performance.  A negative performance could affect your payments as much as -1%.   Please note a group that has not meet their PQRS requirements can have their payments lowered an additional -1.5%.

New HIPPA Rules Affect Patient Billing

A new rule goes into effect this week that can change your self-pay billing in a very unique way as of March 26th. Consider this, a patient who pays out of pocket can now request that their insurance NOT be billed.  The biller has to comply with this request.  If you do not comply with this request it is now a HIPPA violation.

Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

That’s right. For free.

Share This