Industry News

National Provider Identifier (NPI)

Attention all health care providers - by May 23 2007 YOU must have an NPI, or your cash flow and business may be jeopardized:
The good news is that obtaining your NPI is relatively simple - the bad news is that the changeover from the present system to the National Provider System (NPS) and the NPI may be confusing and chaotic, and comparatively few providers have actually applied for their NPI.

More details

Application Form

CMS Office of Public Affairs

CMS announced on March 18, 2008 that National Government Services has been awarded a contract to administer Part A and Part B Medicare claims payments in Connecticut and New York. NGS will serve as the first point of contact for the processing and payment of Medicare claims from hospitals, skilled nursing facilities, physicians and other health care practitioners. The new contractor will take over claims payment work now performed by two fiscal intermediaries and four carriers in the two states. This is a major change from the current system, in which fiscal intermediaries process claims for Medicare Part A providers, such as hospitals, skilled nursing facilities and other institutional providers and carriers process claims for physicians, laboratories and other practitioners under Medicare Part B.

CMS wants the "A/B MACs" to provide enhanced provider customer service, increased payment accuracy, improved provider education and training leading to correct claims submissions, and realized cost savings resulting from efficiencies and innovation. When contracting reform is fully implemented, all the fiscal intermediaries and carriers will be replaced by MACs responsible for both Part A and Part B claims processing. For beneficiaries and providers, the new structure will mean that they each will have a single point of contact with the Medicare program. The MAC for Connecticut and New York will be the contact for all Medicare providers and physicians in the two states, while beneficiaries will pose their claims-related questions to a Beneficiary Contact Center. CMS awarded the first A/B MAC contract in July 2006 to Noridian Administrative Services, LLC, headquartered in Fargo, N.D. The list of new contractors and the states they cover, along with other information, can be found here. It is anticipated that by 2011 all states will be served by a MAC.

Now You Can Have Your Say

The Physicians Regulatory Issues Team (PRIT) is a group of CMS subject matter experts who work with Dr. William Rogers to reduce the regulatory burden on physicians who participate in the Medicare Program. Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients. "It is my goal to simplify the lives of physicians by the elimination of unnecessary regulation, and help make Medicare participation a pleasure rather then a burden." - Dr. William Rogers

Contact Information:

E-Mail questions or concerns to:
prit@cms.hhs.gov

Dr. Rogers can be reached at:
202-236-3338 or william.rogers@cms.hhs.gov

Medicare Learning Network

The Medicare Learning Network is the new name for official CMS national provider education products designed to promote national consistency of Medicare provider information. Medicare providers are often faced with uncertainty when it comes to relating to major policy changes such as the Medicare Modernization Act. The Medicare Learning Network aims to solve that problem by providing a variety of training and educational materials that present Medicare policy in plain language and show you how you are affected. Presentation formats include the Internet, national educational articles, brochures, fact sheets, web-based training courses, and videos, to deliver a planned and coordinated provider education program. In the Downloads section at the bottom of this page you will find links to:

• MLN Products Catalog--an interactive catalog that provides descriptions and link to all MLN educational products and resources.
• Provider Call Center Toll-Free Numbers Directory--this directory offers providers information on how to contact the appropriate provider call center.
• MLN Videos - Quick and basic information about the MLN and its benefits to providers.

RAC - Recovery Audit Contractors

"Recovery Audit Contractors" are a pilot project by the CMS in its goal to eradicate problems, overpayment and also underpayment in the Medicare / Medicaid system. The first demonstration program in California, New York and Florida (states with the most Medicare claims) has netted $440 million in improper payments in 2007 alone. The approach begins to go national starting this year, to be completed by 2010. Medicare processes more than 1.2 billion Medicare claims annually, submitted by more than one million health care providers, including hospitals, skilled nursing facilities, physicians and medical equipment suppliers. Erroneous claims account for billions of dollars in improper payments each year. More than 85 percent of the overpayments collected by RACs and almost all underpayments refunded by the RACs were from claims submitted by inpatient hospitals. 96 % of improper payments identified by the RACs in 2007 were overpayments regained from providers; the remaining 4 percent were underpayments repaid to providers. Inadvertent errors leading to improper payments found by the RACs, include the following examples:

• A health care provider bills Medicare for conducting three colonoscopies on the same patient on the same day;
• Payments are made for services that are coded incorrectly - for example Medicare is billed for a certain procedure but the medical record shows that a different procedure was actually provided;
• A health care provider is paid twice because the provider submitted duplicate claims;
• A claim is paid using an outdated fee schedule.

In such cases the RAC would issue a repayment request for the amount that was paid for the extra service or the incorrect coding. If the beneficiary paid wrong co-payment amounts, the health care provider would need to reimburse the patient for those co-payments. Medicare calculates the error rate - the amount of incorrect claims that are submitted by health care providers - as part of the Comprehensive Error Rate Testing (CERT) program. Since CMS began the program, the error rate dropped from 14.2 percent in 1996 to 3.9 percent in 2007.
For more information on the RAC program and to view the FY 2007 Status Document, visit: http://www.cms.hhs.gov/RAC

Nursing Homes in the News

On November 29, 2007 the agency began publishing the names of Special Focus Facility (SFF) nursing homes that had failed to improve significantly after being given the opportunity to do so. Designated SFFs receive twice the number of standard surveys and progressive enforcement until they either (a) significantly improve and are no longer identified as an SFF, (b) are granted additional time due to promising developments, or (c) are terminated from Medicare and/or Medicaid.
Between November and February, CMS worked with states to assure that the SFF list is current and provides consumers with the information needed to make a distinction between nursing homes that are improving and those that are not. Those on the list are among the 5 to 10% poorest in each state. About 131 active facilities are on the list. The CMS data indicate that about 50 percent of the nursing homes identified as SFFs significantly improve their quality of care within 24-30 months, while about 16 percent are terminated from Medicare and Medicaid.
The Feb 12 2008 release includes a broader list of all nursing homes identified in the SFF initiative. This updated and expanded list identifies facilities by the category they fall within, such as:

• New Additions: nursing homes added within approximately the past six months;
• Not Improved: nursing homes that have failed to improve significantly in at least one survey after being named as a SFF nursing home;
• Improving: nursing homes that have significantly improved on the most recent survey, including no findings of harm to any resident and no systemic potential for harm;
• Recently Graduated: nursing homes that have sustained significant improvement for about 12 months, indicating an upward trend in quality improvement compared to the nursing home's prior history of care;
• No Longer in Medicare and Medicaid: nursing homes that were either terminated by CMS from participation in Medicare within the past few months, or voluntarily chose not to continue participation.

Serious deficiencies include failing to give residents their medications in the correct dose at the correct time, taking steps to prevent abuse or neglect, inappropriate use of restraints and failure to prevent or properly treat bed sores.

Healthcare Reference Tools

U.S. Department of Health and Human Services (HHS)Office of Inspector General (OIG)
If you have identified billing practices that cause you to suspect potential fraud or abuse, call the OIG's National Hotline at 1-800-HHS-TIPS (1-800-447-8477) to report the activity.

Contacting the HHS OIG Hotline

• Phone: 1-800-HHS-TIPS (1-800-447-8477)
• Fax: 1-800-223-8164
• E-Mail: HHSTips@oig.hhs.gov
• TTY: 1-800-377-4950
• Mail: Office of Inspector General Department of Health and Human Services Attn: HOTLINE 330 Independence Ave., SW Washington, DC 20201

For questions about billing procedures, billing errors, or questionable billing practices contact your Medicare Contractor. You can find FI and Carrier contact information, including toll-free telephone numbers, here on the CMS website.