2019 UPDATES:

NEW MEDICARE BENEFICIARY IDENTIFIERS

CMS has changed the terminology from Medicare Card to Medicare Beneficiary Identifiers (MBI’s). Effective January 1, 2020 the new MBI must be used. Caution should be exercised to ensure that the numbers are interpreted properly. To avoid confusion on the alpha numbers zero – nine, CMS does not use the letters B, I, L, O, S. Providers should ensure that a zero is not being interpreted an “O”. If a patient does not have their new Medicare card with them the MBI can be looked up on the Medicare Contractors website.

MACRA/MIPS

Providers are encouraged to monitor their MIPS score to ensure that they met the requirements for avoiding the 9% penalty in 2022. The year 2020 claims filing/registry will be used as the base year for determining compliance for avoiding the 9% penalty in 2022. On the other side of the equation, many providers are not receiving as large of bonus for participation as was anticipated.

FLORIDA DECEPTIVE INSURANCE PRACTICES

Chapter 690-153 of the Florida Administrative Code contains the Deceptive Insurance Practices statue. The statue states “The submission or presentation for payment to an insurer, health maintenance organization or third party of a claim form, bill or other statement for services rendered, prepared or signed by health care provider or healthcare facility which does not disclose a pre-provision of services agreement between the healthcare provider or healthcare facility and the patient to accept less for the healthcare service rendered than is reflected on claim form, bill or statement is an example of a false claim.” In essence, if a patient is to be given a discount it must be reflected on the insurance bill to the organization.

Section 690-153.004 states; a healthcare provider shall disclose to the payer by one of the following methods: (1) attaching a copy of the agreement to the claim form; (2) attaching a statement that discloses the agreement in specific terms thereof; and (3) attaching a copy of the policy which provides for the waiver of all or some portion of the deductible or co-payment for employees of the hospital and others and a representation that the waiver is authorized by policy as to that provider; (4) attaching a disclosure of the office; approved uniformed claim form when modified to effectuate such disclosure in a uniform manner as to all claims.” It is recommended that there not be courtesy discounts given to avoid a violation of this Code.

CLEARINGHOUSE

Providers are encouraged to check with their clearinghouse to ensure claims are not be held to batch with claims from other providers. It has been reported that some clearinghouses hold claims until they have a large group and transmit the insurance claim weekly or bi-weekly. This method will delay the processing of a claim.

HIPAA SECURITY

Providers need to ensure that they have a HIPAA Security Risk Analysis performed on an annual basis. This is a review of the electronic Protected Health Information (e-PHI) to ensure it is appropriately safeguarded. This includes all methods of e-PHI such as electronic media, hard drives, cd’s, dvd’s, smart cards, flash drives or other smart devices, personal digital assistants, transmission media or portable electronic media. This may include a cell phone/smart phone or tablet. It is recommended that practices have written policies that they maintain and enforce to ensure that portable devices are appropriately protected. This can be a challenge as many employees will have access to e-PHI via their cell phones or tablets however, it is their private device that must be protected. REMINDER: All transmitted PHI by any electronic means must be secured and preferably be encrypted.

MEDICARE ENROLLMENT

Providers need to ensure that they update any changes to the provider number on a regular basis. A common area that leads to trouble is the provider may have had a medical license and Medicare number in another state however, instead of choosing to relinquish their license since they are no longer practicing in that state, the provider would allow the license to lapse. As a result, this is shown as an Adverse Action in that state as the providers medical license has expired. Should this occur, the provider should contact their local Medicare Contractor and let them know of this Adverse Action on their license. When enrolling a provider, find out the providers history of where they have had medical licenses and Medicare provider numbers and ensure that these are de-activated appropriately to avoid such issues. A Physician can be suspended from Medicare for up to three years for submitting false information on their Medicare Enrollment Application.

MEDICARE REFUNDS

Medicare requires providers and suppliers to report and return overpayments by 60-days after the date an overpayment is identified. This rule applies to Part A and Part B providers and suppliers with Medicare Parts C and D.

Providers and suppliers who do not comply with this 60-day deadline could be subject to false claims liability, treble damages plus $11,000 per claim, civil monetary penalties, and exclusion from the Medicare and Medicaid programs.

Overpayments must be reported and returned if a provider or supplier identifies the overpayment within six years of the date of the overpayment was received.

NON-MEDICARE REFUNDS

The State of Florida has their own requirements for refunds. In addition to the refund requirements, the State can audit accounts to determine if refunds were due and not made for up to 10 years.