Advance Beneficiary Notice of Noncoverage

Transcription

1 Advance Beneficiary Notice of Noncoverage Presented by Noridian Provider Outreach and Education Jurisdiction D DME MAC October

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2013 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. October 2013 Noridian Jurisdiction D DME MAC 2 2

3 Workshop Protocol Entering Workshop Attendee lines are muted upon entry Throughout Workshop Written questions in Q & A section Please do not use the chat feature Conclusion of Workshop: Q & A Session Use Raise Hand feature to ask questions aloud Certificate of Completion 1 AAPC CEU is offered for this course Certificate of Completion will be sent out to all attendees 2-3 days after workshop based on attendance report Presentation was sent via , is also available at October 2013 Noridian Jurisdiction D DME MAC 3 3

4 Acronyms ABN: Advance Beneficiary Notice of Noncoverage CERT: Comprehensive Error Rate Testing CMS: Center for Medicare & Medicaid Services DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics & Supplies IOM: Internet Only Manual LCD: Local Coverage Determination Resources ronyms.html er=all October 2013 Noridian Jurisdiction D DME MAC 4 4

5 Agenda Definition and Purpose Acceptable ABN Unacceptable ABN Completing the ABN Modifiers ABNs and Upgrades Resources and Reminders October 2013 Noridian Jurisdiction D DME MAC 5 5

6 CERT 2012 Improper Payment Rates October 2013 Noridian Jurisdiction D DME MAC 6 6

7 Definition and Purpose 7

8 Definition and Purpose Written notice of noncoverage Informs beneficiary that Medicare may not pay for an item Must be issued before the item/service is provided Allows beneficiary to make informed decision whether to receive the item Beneficiary liable for payment Protects supplier from liability October 2013 Noridian Jurisdiction D DME MAC 8 8

9 Triggering Events Initiations New beneficiary encounter; start of plan of care; beginning of treatment Reductions Decrease in a component of care Terminations Discontinuation of certain items/services October 2013 Noridian Jurisdiction D DME MAC 9 9

10 Acceptable ABN 10

11 ABN Standards Must meet readability requirements Use an approved standard form CMS-R-131 (03/11) Specificity, Delivery and Receipt, Timeliness Item must be clearly written Written in terms beneficiary i or authorized representative can understand Delivered to beneficiary by qualified notifier before item is furnished Delivered ABN in person to the beneficiary Delivered ABN via other means to the beneficiary October 2013 Noridian Jurisdiction D DME MAC 11 11

12 Statutorily Excluded Items Services with no legal obligation to pay Services paid by government entity other than Medicare Personal comfort items Routine physicals and most screening tests Bath tub/shower chair Exercise equipment Telephone communication system (e.g., Life Alert) Voluntary ABN Does not meet definition of a Medicare benefit Parenteral/enteral nutrients to treat temporary condition or are administered orally Infusion drugs not administered through infusion pump Surgical dressings used to clean wounds or intact skin or provide protection to intact skin Irrigation supplies used to irrigate skin or wounds Immunosuppressive drugs used for conditions other than following organ transplants October 2013 Noridian Jurisdiction D DME MAC 12 12

13 ABN-Mandatory Use Services always denied d for medical necessity Frequency limited items Denial of advance determination of Medicare coverage (ADMC) Certain instances of upgrades No Medicare supplier number Unsolicited telephone contact made by supplier Noncontract supplier furnishing DMEPOS in competitive bid area (effective 9/4/12) October 2013 Noridian Jurisdiction D DME MAC 13 13

14 Unacceptable ABN 14

15 Unacceptable ABN Unreadable or illegible Beneficiary incapable of understanding the ABN ABN given to beneficiary during an emergency, under duress, coerced or misled ABN delivered to beneficiary more than one year before item was furnished October 2013 Noridian Jurisdiction D DME MAC 15 15

16 Defective Notices Routine ABN No specific, identifiable reason to believe Medicare will not pay Generic ABN Stating Medicare may not pay Blanket ABN Giving ABNs for all items Signing blank ABN Obtaining beneficiary signature on blank ABN; completing ABN later October 2013 Noridian Jurisdiction D DME MAC 16 16

17 Completing the ABN 17

18 ABN Instructions Use ABN form CMS-R-131 (03/11) Typed or hand-written on a single page Blanks (A)-(F), and (H) may be completed prior to delivery Verbally review with beneficiary Deliver in advance Beneficiary receives a paper copy, notifier keeps original May include voluntary notification for items that are not Medicare benefits October 2013 Noridian Jurisdiction D DME MAC 18 18

19 Who May Sign an ABN? The beneficiary If beneficiary is incapable or incompetent Authorized representative Individual under state law authorized to make health decisions The spouse, unless legally separated An adult child A parent An adult sibling A close friend An adult who has exhibited special care/concern for the beneficiary, who is familiar with the beneficiary s personal values, and who is reasonably available October 2013 Noridian Jurisdiction D DME MAC 19 19

20 ABN Header Blank A Notifier s name, address, telephone number Blank B Beneficiary s name as listed on Medicare card Blank C Internal identification number (optional) Cannot use Medicare or social security number October 2013 Noridian Jurisdiction D DME MAC 20 20

21 ABN Body Item Item Item Enter specific item Enter frequency and/or duration of item Reduction in an item/supplies Enter reason Medicare may not pay for item (be specific) Enter reasonable estimated cost to the beneficiary October 2013 Noridian Jurisdiction D DME MAC 21 21

22 ABN Options October 2013 Noridian Jurisdiction D DME MAC 22 22

23 Additional Information and Signature October 2013 Noridian Jurisdiction D DME MAC 23 23

24 Example 1 (Section E Needs Improvement) October 2013 Noridian Jurisdiction D DME MAC 24 24

25 Example 2 (Acceptable) October 2013 Noridian Jurisdiction D DME MAC 25 25

26 Example 3 (Acceptable) October 2013 Noridian Jurisdiction D DME MAC 26 26

27 Example 4 (Unacceptable Section E) October 2013 Noridian Jurisdiction D DME MAC 27 27

28 Example 5 (Unacceptable Section E) October 2013 Noridian Jurisdiction D DME MAC 28 28

29 Example 6 (Unacceptable Incomplete, Signature) October 2013 Noridian Jurisdiction D DME MAC 29 29

30 Example 7 (Unacceptable Incomplete, Outdated Form) October 2013 Noridian Jurisdiction D DME MAC 30 30

31 Other Examples for Section E Valid The beneficiary does not have the required diagnosis to qualify for this item per the Medicare policy. The beneficiary currently has a standard wheelchair (K0002) paid for by Medicare on 12/2/2009 which is same or similar to this power wheelchair (K0823). Invalid Beneficiary might have similar equipment on file. Medicare may not pay for this item. Beneficiary may not be eligible for Medicare Part B at this time. Not enough supporting documentation in the medical record. October 2013 Noridian Jurisdiction D DME MAC 31 31

32 Financial Liability Fail to issue a mandatory ABN Issue a defective ABN Refund beneficiary in a timely manner - 30 days after getting the remit - 15 days after determination on an appeal October 2013 Noridian Jurisdiction D DME MAC 32 32

33 Modifiers 33

34 ABN Modifiers GA and GZ GA Modifier Waiver of Liability statement on file Supplier expecting not medically necessary denial Mandatory ABN is properly executed GZ Modifier Item or service expected to deny as not reasonable or necessary No ABN obtained All claim line(s) with a GZ modifier shall be denied automatically and will not be subject to complex medical review October 2013 Noridian Jurisdiction D DME MAC 34 34

35 ABN Modifiers - GY Item or service statutorily excluded: Examples include: hearing aids most dental items personal comfort items Does not meet definition of any Medicare benefit Examples (not all-inclusive): Prosthetic device for temporary conditions Immunosuppressive drugs used for conditions other than following Medicare covered transplant DME used only outside the home October 2013 Noridian Jurisdiction D DME MAC 35 35

36 ABNs and Upgrades 36

37 ABN Modifiers - Upgrades GK Actual item ordered d by physician i GL Medically unnecessary upgrade provided instead of standard item, no ABN on file Supplier not charging for the upgrade October 2013 Noridian Jurisdiction D DME MAC 37 37

38 Upgrades October 2013 Noridian Jurisdiction D DME MAC 38 38

39 Upgrade: With ABN, Charging Difference to Beneficiary ABN must be obtained Line 1: HCPCS provided with GA Line 2: HCPCS that meets criteria with GK KX if appropriate per policy Must bill in this order E0265 RR KH GA E0260 RR KH KX GK October 2013 Noridian Jurisdiction D DME MAC 39 39

40 Upgrade: Provided at No Charge Physician ordered upgrade or Upgrade provided for supplier convenience No ABN obtained Do not bill HCPCS for item provided Bill HCPCS meeting coverage criteria with GL KX if appropriate for policy Item provided must be listed in narrative K0001 RR KH KX GL October 2013 Noridian Jurisdiction D DME MAC 40 40

41 Resources and Reminders 41

42 LCD/Policy Article Resources Supplier Manual Dear Physician letters Documentation Checklist com/dme/coverage/checklists html October 2013 Noridian Jurisdiction D DME MAC 42 42

43 MAC Satisfaction Indicator Your opinion counts! MSI is a tool that measures your satisfaction with the Medicare claims administrative contractor(s) that serve you Participation is voluntary, but you must register if you would like to take the MSI. A random sample will be drawn from the registry. gov/medicare/medicare-contracting/msi/ Let your voice be heard October 2013 Noridian Jurisdiction D DME MAC 43 43

44 PECOS Requirement Claims may be denied if: The ordering/referring physician is NOT in PECOS and eligible to order and refer The ordering/referring physician is not of the specialty to order/refer If the physician's name submitted on the claim does not match their name in PECOS Remittance Advice: N544 warning messages see how to avoid these claim denials by properly submitting the ordering physician name from the CMS PECOS Report October 2013 Noridian Jurisdiction D DME MAC 44 44

45 Written Order Prior to Delivery and Face-to-Face Encounter Affected DME requires: Face-to-face evaluation within six months prior to order Sooner if required by LCD May be performed by MD, DO, NP, PA or CNS Must be received by supplier prior to delivery of DME WOPD Detailed written order must be received by the supplier prior to delivery of DME NPI must be included on WOPD Implemented 7/1/13 MLN MM8304-Revised October 2013 Noridian Jurisdiction D DME MAC 45 45

46 Updates Tuesday and Friday Latest updates and announcements Customizable Tutorial October 2013 Noridian Jurisdiction D DME MAC 46 46

47 Website Survey October 2013 Noridian Jurisdiction D DME MAC 47 47

48 MREP Medicare Remit Easy Print Free software! View, search and print remits Print and export reports CMS Brochure mit_0408.pdf MREP Software RemitEasyPrint.asp October 2013 Noridian Jurisdiction D DME MAC 48 48

49 Medicare Learning Network (MLN) MLN Product and Resource Guide Guides Articles Educational Tools Booklets Brochures Fact Sheets Training Presentations Web-Based Training Special Initiatives Web Resources Network-MLN/MLNGenInfo/index.html October 2013 Noridian Jurisdiction D DME MAC 49 49

50 New Recoupment Process Suppliers can now elect to have overpayments repaid through immediate recoupment process (CR 7688) Must submit Request for Immediate Recoupment Form: ment.pdf For more information, see: ate_recoupment_for_claims_overpayments_definition_of_proces s_suppliers_may_use.html October 2013 Noridian Jurisdiction D DME MAC 50 50

51 Endeavor Functions Availability Eligibility Eligibility Claim Status 24 hours/day, 7 days/week Same or Similar All other functions Claim-Specific ifi Remittance 6am a.m. 8pm p.m. CT, Mon. Fri. Advices 7 a.m. 3 p.m. CT, Sat. Overpayments Reopening/Redetermination Submission Status t Inquiry PMD Prior Auth Request Status October 2013 Noridian Jurisdiction D DME MAC 51 51

52 Education Opportunities Web-Based Workshops Nebulizers Medical Review Program In-Person Seminars Sacramento Santa Rosa DME On Demand ACT October 3 p.m. CT October 2013 Noridian Jurisdiction D DME MAC 52 52

53 Contact Information Supplier Contact Center 8:00 a.m. 6:00 p.m. CT M-F Interactive Voice Response (IVR) 24/7 Eligibility 6:00 a.m. 8:00 p.m. CT M-F for claim status Telephone Reopenings 8:00 a.m. 4:30 p.m. CT M-F October 2013 Noridian Jurisdiction D DME MAC 53 53

54 Questions 54

55 Thank you for attending! 55