Private Sector Advocacy

Reporting & Returning of Medicare Overpayments

The Centers for Medicare and Medicaid Services (CMS) published a final rule pursuant to Section 1128J(d) of the Social Security Act, as amended by the Affordable Care Act, that requires Medicare Parts A and B health care providers to report and return overpayments 60 days after the date an overpayment is identified, or the due date of any corresponding cost report, if applicable, whichever is later. The rule requires providers to maintain responsible compliance practices and conduct a reasonably diligent inquiry when credible information indicates that an overpayment may exist. These regulations are effective 30 days after the date of publication in the Federal Register, or March 13, 2016.

Information on ICD-10 grace period

On July 7, the American Medical Association and Centers for Medicare and Medicaid Services (CMS) jointly announced that agreement has been reached on important elements of a “grace period” for the October 1, 2015, implementation of the ICD-10 diagnosis code set. Some highlights:

  • For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.
  • CMS will establish an ICD-10 Ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition.
  • CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation.

The AMA will monitor and keep CMS apprised of any implementation issues that persist in 2016, and will urge the agency to make any needed adjustments to the grace period policy and timeline. Time is running out for physician practices to complete preparation ahead of the October 1 implementation deadline. The AMA has a broad range of materials available on its website to help physicians prepare for the October 1 deadline.

Network Termination Toolkit

As healthcare reform initiatives proceed and health insurers attempt to become more financially competitive in an expanding, cost conscious market place, many insurers have decided to decrease the number of network providers. Many Mohs surgeons have received notice of termination from their provider contracts. Maintaining as wide a menu of accepted medical insurances is the lifeblood of most Mohs surgery practices, and many Mohs surgeons will choose to respond to the termination in an attempt to reverse this decision. Acting rapidly and by as many means as possible will give the provider the best chance of having the termination delayed or rescinded.

The American Academy of Dermatology has put together an excellent outline for responding to network termination--visit the AAD Advocacy page here and click on the Network Adequacy section (third row down; requires AAD member login), or try searching for "responding to network termination" using the search function. The more detailed guide below is more targeted for termination from Humana, but the general concepts may apply to other carriers as well. These steps have been gleaned from discussion with ACMS members about their experiences with Humana termination and are meant to help educate our members on the likely course of the appeal process with Humana. This process may change with time and/or be different in individual cases.