All posts by Experian Health

At HHS, we’re working today with an eye on the horizon. We’re committed to building a health care system that provides better care, spends our health care dollars in smarter ways, and puts patients at the center of their care. Our aim is to strengthen health care so that it works for the health of every American. Our vision for this health care system is one where a patient can easily check their own medical record, where a patient’s different clinicians, from pharmacists to nurses to physicians, can more seamlessly work together to keep that patient healthy, and where treatment can easily be tailored to a specific patient’s needs. The key to unlocking that vision of a modern health care system is joining the data revolution that has already transformed so much of our society. Just recently, Secretary Burwell spoke at the 2016 conference of the Healthcare Information and Management Systems Society. She spoke about our need to unlock data to bring health care into the 21st century and how the security of patient data is essential to our progress. As she told the audience, “People should be able to easily and securely access their electronic health information and send it to any desired location. They need to be able to understand how their information can be shared and used. And they must be assured that this information will be effectively and safely used to benefit their health and that of their community.” Today, we’re taking a significant step to improve the safety of the data and security of life-saving medical devices across our health care system by announcing the membership of the Health Care Industry Cybersecurity Task Force. The members of this Task Force are leaders in government and private industry. They’re innovators in technology and pioneers in health care. They represent organizations of various sizes, and they hail from different parts of the country. Over the next year, these individuals will collectively look across industries and sectors to find the best ways organizations of all types are keeping data and connected medical devices safe and secure. They’ll discuss these ideas among themselves and, in the next year, they’ll report their findings to Congress and the public. They’ll also develop materials to share widely, ensuring every organization that plays a part in our health care system can protect the data that that is part of this system. As President Obama has made clear, cybersecurity is one of the most serious security challenges that our nation faces. So as we look to transform our health care system into one that works better for all Americans, we need to ensure it works safely for all Americans. We need to protect the data at the foundation of our health care system. That’s our commitment here at HHS, and it’s why we’re so excited to launch the Health Care Industry Cybersecurity Task Force.

On March 16, CMS released three special edition MLN Matters articles on submitting claims to MACs for chiropractic services provided to Medicare beneficiaries. Special edition MLN Matters article SE 1601 helps clarify the CMS policy regarding Medicare coverage of chiropractic services and documentation requirements for the beneficiary’s initial visit and subsequent visits to the chiropractor. Special edition MLN Matters article SE 1602 explains the Active Treatment modifier (AT), which was developed to clearly define the difference between active treatment and maintenance treatment. Special edition MLN Matters article SE1603 provides a detailed list of informational/educational resources that can help chiropractors avoid billing errors due to insufficient or inaccurate documentation. Read More: MLN Matters article SE 1601: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1601.pdf MLN Matters article SE 1602: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1602.pdf MLN Matters article SE1603: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1603.pdf

On March 11, CMS released a change request to display the list of telehealth services that were once available through the manual updates to now be displayed via a weblink going forward. CMS is also adding CRNAs to the list of Medicare practitioners who may bill for covered telehealth services. Lastly, the telehealth language has been removed from Pub 100.02, Medicare Benefit Policy Manual, Chapter 15, Section 270 and a reference added in text to see Pub 100.04, Chapter 12, Medicare Claims Processing Manual, section 190 for further information regarding telehealth services. Implementation date: April 11, 2016 Transmittal R3476CP here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3476CP.pdf Transmittal R221BP here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R221BP.pdf MLN Matters article MM9428 here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9428.pdf

On March 11, CMS posted a transmittal stating it awarded Noridian Healthcare Solutions, LLC, a new contract for the administration of Medicare Fee-for-Service claims for DME, prosthetics, orthotics, and supplies in Jurisdiction A. The incumbent is NHIC, Corp. The Jurisdiction A DME MAC serves Medicare beneficiaries who reside in the states of Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont, and the District of Columbia. Under this contract, Noridian will process and pay Medicare DMEPOS claims; process redetermination requests; respond to supplier inquiries; perform supplier outreach and education; and, review claims for medical necessity. Noridian will begin processing Jurisdiction A claims in May 2016 from its offices in Fargo, ND. Jurisdiction A includes over 8.2 million Medicare Fee-for-Service beneficiaries. The Jurisdiction A DME MAC will serve approximately 20,000 Medicare DMEPOS suppliers. This jurisdiction comprises nearly 18% of the overall national Medicare Fee-for-Service DMEPOS claims volume. The Jurisdiction A DME MAC contract includes a base year and four option years, for an anticipated duration of five years. The contract is a “cost plus award fee” contract; the award fee will be earned only if the contractor exceeds the base requirements of the contract. Effective date: December 16, 2015 Implementation date: July 1, 2016, for all cutover requirements outside of those related to system changes; July 5, 2016, for system changes View Transmittal R1634OTN here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1634-OTN.pdf View MLN Matters article MM9546 here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9546.pdf

CMS recently released an extensive revision of QIO Manual Chapter 9 related to QIO reviews in cases potentially involving sanction recommendations from the OIG for quality and EMTALA issues. The chapter has been renamed to include the reference to EMTALA. This update supersedes all the information in the October 3, 2003 version of Chapter 9, any previously issued Question & Answer guidance, and any previously issued TOPS, Standard Data Processing System, and Healthcare Quality Information System memos related to Chapter 9. Effective date: March 14, 2016 Implementation date: March 14, 2016 View Transmittal R139DEMO.

On March 17th, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) released a new interactive map to increase understanding of geographic disparities in chronic disease among Medicare beneficiaries. The Mapping Medicare Disparities (MMD) Tool identifies disparities in health outcomes, utilization, and spending by race and ethnicity and geographic location. Understanding geographic differences in disparities is important to informing policy decisions and efficiently targeting populations and geographies for interventions. “Our commitment to health equity begins with properly measuring the care people get and having an honest dialogue on how and where we need to improve,” said CMS Acting Administrator Andy Slavitt. “Today’s tool aims to make it harder for disparities to go unaddressed.” Racial and ethnic minorities experience disproportionately high rates of chronic diseases, and are more likely to experience difficulty accessing high quality of care than other individuals. The identification of areas with large differences in the proportions of Medicare beneficiaries with chronic diseases is an important step for informing and planning health equity activities and initiatives. The Mapping Medicare Disparities Tool features: A dynamic interface with data on the prevalence of 18 chronic conditions, end stage renal disease, or a disability; Medicare spending, hospital and emergency department (ED) utilization, preventable hospitalizations, readmissions, and mortality rates. The ability to sort by state or county of residence, sex, age, dual-eligibility for Medicare and Medicaid, and race and ethnicity. Built-in benchmarking features to investigate disparities within counties and across racial and ethnic groups, and within racial and ethnic groups across counties. “It’s not enough to improve average health care quality in the U.S.,” said CMS OMH Director Cara James.  “As the CMS Equity Plan lays out, we must identify gaps in quality of care at all levels of the health care system to address disparities. We are excited to share this new tool, which allows us to pinpoint disparities in health care outcomes by population and condition.” See the Medicare Mapping Disparities Tool here: https://www.cms.gov/About-CMS/Agency-Information/OMH/OMH-Mapping-Medicare-Disparities.html The Medicare Mapping Disparities Tool FAQ’s are here:https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/MMDT-FAQs.pdf  

Beginning in 2016, claims for CT (Computed Tomography) scans identified by the CPT codes listed  below  (and by successor codes) that are furnished on non-NEMA (National Electric Manufacturers Association) Standard XR-29-2013-compliant CT scans must include modifier “CT” that will result in an applicable payment reduction. 70450-70498 71250-71275 72125-72133 72191-72194 73200-73206 73700-73706 74150-74178 74261-74263 75571-75574 CMS Change Request (CR) 9250 informs providers that effective January 1, 2016, a payment reduction of 5 percent applies to CT services furnished on equipment that is inconsistent with the CT equipment standard and for which payment is made under the physician fee schedule. When such payment reductions are made, MACs will supply: Claim Adjustment Reason Code 237 – Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Remittance Advice Remark Code N759 – Payment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013; and Group Code: CO (contractual obligation) The payment reduction increases 15 percent in 2017 and subsequent years. System attestation by providers will be verified through the periodic supplier accreditation process. Read the official instruction here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3402CP.pdf

The Centers for Medicare & Medicaid Services (CMS) published a final rule February 11, 2016 that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable. A separate final rule was published in the May 23, 2014 Federal Register (79 FR 29844) that addresses Medicare Parts C and D overpayments. Summary The requirements in this rule are meant to support compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against improper payments, including fraudulent payment. This rule clarifies requirements for the reporting and returning of self-identified overpayments. Health care providers and suppliers have been and will remain subject to the statutory requirements found in section 1128J(d) of the Social Security Act (the Act) and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment. Health care providers and suppliers will also continue to be required to comply with current CMS procedures when we, or our contractors, determine an overpayment exists and issue a demand letter. Background Section 6402(a) of the Affordable Care Act established a new section 1128J(d) of the Act. Section 1128J(d)(1) of the Act requires a person who has received an overpayment to report and return the overpayment to the Secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and to notify the Secretary, state, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment. Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of: (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable. Section 1128J(d)(3) of the Act specifies that any overpayment retained by a person after the deadline for reporting and returning an overpayment is an obligation (as defined in 31 U.S.C. 3729(b)(3)) for purposes of 31 U.S.C. 3729. In the February 16, 2012 Federal Register (77 FR 9179), CMS published a proposed rule to implement the provisions of section 1128J(d) of the Act for Medicare Parts A and B providers and suppliers. Major Provisions The major provisions of this final rule include clarifications around: the meaning of overpayment identification; the required lookback period for overpayment identification; and the methods available for reporting and returning identified overpayments to CMS. Meaning of “Identification” Section 1128J(d) of the Act provides that an overpayment must be reported and returned by the later of: (i) the date which is 60 days after the date on which the overpayment was identified; or (ii) the date any corresponding cost report is due, if applicable. This final rule states that a person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment. Creating this standard for identification provides needed clarity and consistency for health care providers and suppliers regarding the actions they need to take to comply with requirements for reporting and returning of self-identified overpayments. Lookback Period Under this final rule, overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received. Specifying the length and other parameters of the look back period provides additional clarity for providers and suppliers who have identified an overpayment that is covered by the provisions of 1128J(d). How to Report and Return Overpayments This final rule provides that providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments. This approach for returning overpayments provides an array of familiar options from which providers and suppliers can select. This rule also provides that if a health care provider or supplier has reported a self-identified overpayment to either the Self-Referral Disclosure Protocol managed by CMS or the Self-Disclosure Protocol managed by the Office of the Inspector General (OIG), the provider or supplier is considered to be in compliance with the provisions of this rule as long as they are actively engaged in the respective protocol. View the final rule in the Federal Register here: https://www.gpo.gov/fdsys/pkg/FR-2016-02-12/pdf/2016-02789.pdf

Experian Health is pleased to announce that its Patient Estimates solution has joined the athenahealth® Marketplace, also known as  the More Disruption Please (MDP) program. Experian Health has participated in this program since the launch of the marketplace in 2013 (starting with our Contract Management offerings) and has worked with athenahealth to integrate its industry-leading capabilities into the organization’s growing network of more than 73,000 healthcare providers. Learn more about Experian Health’s Patient Estimates solution. Read the press release To learn more about athenahealth’s MDP program and partnership opportunities, please visit https://www.athenahealth.com/disruption.