Radiology Notification Program: Process for Rendering Providers when Services are Ordered by Non-Participating Physicians

For claims with dates of service September 7, 2010 and thereafter, UHC requires rendering providers to submit notification for services ordered by non-participating physicians when no notification is on file, in accordance with the Radiology Notification protocol for commercial benefit plans set forth in the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. If the rendering provider does not provide notification for services ordered by a non-participating physician, the rendering provider’s claim will be denied for failure to provide notification and the member cannot be billed. Furthermore, UnitedHealthcare will uphold on appeal any claims denied for failure to provide notification that are appealed on the basis that the ordering physician is a non-participating provider.

If the ordering physician is a participating provider, the rendering provider should not provide notification to UnitedHealthcare. This is the responsibility of the participating ordering physician.

For additional information, here is a link to their web site.

Thursday, August 19, 2010:  The Somerset Health Care Team will host a seminar/webinar on banking, tax & valuation issues affecting the health care industry on August 19 in a lunch and learn format. Please join us in person or via webinar. There is no charge to participate. http://bit.ly/cpIbK3

On June 25, 2010, President Obama signed into law the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.”  This law establishes a 2.2 percent update to the Medicare Physician Fee Schedule (MPFS) payment rates retroactive from June 1 through November 30, 2010. The Centers for Medicare & Medicaid Services (CMS) has directed Medicare claims administration contractors to discontinue processing claims at the negative update rates and to temporarily hold all claims for services rendered June 1, 2010, and later, until the new 2.2 percent update rates are tested and loaded into the Medicare contractors’ claims processing systems.  Effective testing of the new 2.2 percent update will ensure that claims are correctly paid at the new rates. We expect to begin processing claims at the new rates no later than July 1, 2010. Claims for services rendered prior to June 1, 2010, will continue to be processed and paid as usual.

Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible.  Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed. Affected physicians/providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact their local Medicare contractor to request an adjustment.  Submitted charges on claims cannot be altered without a request from the physician/provider. 

Physicians/providers should not resubmit claims already submitted to their Medicare contractor.

The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010.  
 
On May 27, 2010, the Centers for Medicare & Medicaid Services (CMS) initially instructed contractors to hold claims for services paid under the MPFS for the first 10 business days of June.  On June 14, CMS extended this hold for an additional three business days (i.e., through June 17, 2010).  This hold only affected MPFS claims with dates of service of June 1, 2010 and later. 
 
The CMS today directed contractors to lift the hold and begin processing June 1 and later MPFS claims under the law’s negative update requirement.  Held claims will be released and processed on a flow basis, first-in/first-out.
 
Congress continues to debate the elimination of the negative update that took effect June 1, 2010.  The CMS is hopeful that Congressional action will be taken to avert the negative update.  We continue to monitor Congressional actions, and if Congress changes the negative update that is currently in effect, we are prepared to act expeditiously to make the appropriate changes to Medicare claims processing systems.

The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010.  At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010.  The Centers for Medicare & Medicaid Services (CMS) is hopeful that Congressional action will be taken within the next several days to avert the negative update.

To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, CMS had instructed its contractors on May 27th to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010).  This hold only affects MPFS claims with dates of service of June 1, 2010, and later.

Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18. 

This action will facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changes the negative update.  It also should minimize the provider and beneficiary burdens and costs associated with reprocessing claims.

We understand that the delayed processing of Medicare claims may present cash flow problems for some Medicare providers.  However, we expect that the delay, if any, beyond the normal processing period will be only a few days.  Be on the alert for more information regarding the 2010 Medicare Physician Fee Schedule Update.

CMS’ 10-day hold on claims is set to end on Monday, June 14th before the U.S. Senate acts on a new SGR fix. 

The House-approved extenders bill is still pending before the Senate, but no votes have been announced on Monday.  If Senate Majority Leader Reid files a cloture motion today, Tuesday morning would be the earliest the Senate would vote on cloture.  Assuming cloture is invoked and the GOP does not insist on the 30 hours of post-cloture debate, the Senate could pass its amendments to the House amendments to the extenders package.  The bill could then be sent over to the House for a vote as early as Tuesday evening – a best case scenario. But, if cloture is not filed until Monday, then Wednesday would be the earliest the bill would see action in the Senate.

It is still unclear the Majority Leader Reid has the 60 votes needed to invoke cloture.  As reported in an RBMA e-Alert last week, concerns over the growing national debt and pay-fors in the Senate are complicating the SGR debate.  This fact has prevented Reid from moving more quickly on the extenders bill. 

CMS has supposedly communicated to the Hill that it would take 48 hours to begin processing claims, so that prevents the SGR cuts from going into effect until at least Wednesday, June 16th. 

The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010.  The Centers for Medicare & Medicaid Services (CMS) believes Congress is working to avert the negative update scheduled to take effect June 1, 2010.  To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the MPFS, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of June.  This hold will only affect MPFS claims with dates of service June 1, 2010, and later. 

This hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. 

Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update. 

We will post additional information from CMS on this issue as soon as it becomes available. We welcome your comments and questions.

Forget January 3, 2011! PECOS Date Moved 6 Months Closer – Referring & Supplying Providers New Date is July 6, 2010
Physicians and “eligible” providers received a jolt today in the May 5, 2010 Federal Register as the date for enrollment in PECOS was moved up (pending the comment period and any changes resulting from the comment period) six months for providers that order or supply durable medical equipment (DME) for Medicare patients.  Instead of the January 3, 2011 date previously announced by CMS, the Patient Protection and Affordable Care Act (Affordable Care Act or PPACA) has provisions to move the go-date to July 6, 2010, just 60 days away.

What does this mean to you? Unless something changes based on public comments, beginning July 6, 2010:

1. Providers with a National Provider Identifier (NPI) must include it on their Medicare and Medicaid enrollment applications and claims.
2. Providers of medical items/other items/services and suppliers that qualify for a National Provider Identifier (NPI) must include their NPI on all applications to enroll in the Medicare and Medicaid programs AND on all claims for payment submitted under the Medicare and Medicaid programs.
3. The ordering/referring supplier must be a physician or an eligible professional with an approved enrollment record in the Provider Enrollment Chain and Ownership System (PECOS) thus changing the previously reported January 3, 2011 date given by CMS.
4. Claims that do not meet these requirements will be rejected by Medicare contractors.

Read the rule in its entirety.

DME clients may want to dial in to the CMS PECOS Open Door Forum on Wednesday, May 19. Details…