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Medicare Updates: Provider Enrollment Revalidation, New Medicare Card, Targeted Probe and Educate, CERT

Stay informed about important Medicare updates including provider enrollment revalidation, the transition to the new Medicare card, targeted probe and educate reviews, and the CERT program.

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Medicare Updates: Provider Enrollment Revalidation, New Medicare Card, Targeted Probe and Educate, CERT

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  1. Noridian Medicare UpdatesPaul O’Donnell - JE Project ManagerScott Oien – External Relations Manager

  2. Provider Enrollment Revalidation

  3. Provider Enrollment Revalidation Why must I revalidate my enrollment file? Patient Protection and Affordable Care act requires provider/suppliers to revalidate their enrollment file approximately every 5 years

  4. Provider Enrollment Revalidation https://med.noridianmedicare.com/web/jeb/enrollment/revalidation • Cycle 1 is complete, Cycle 2 began February 2016 • Establish a 5 year cycle • All active providers/suppliers will be required to revalidate

  5. Provider Enrollment Revalidation • Exceptions – Opt Out, order, certify and prescribe • Submit applications (PECOS preferred) to your Medicare Administrative Contractor within 6 months of due date

  6. Provider Enrollment Revalidation How do I know when to revalidate? https://data.cms.gov/revalidation

  7. Provider Enrollment Revalidation

  8. Medicare Beneficiary Identifier

  9. Medicare Beneficiary Identifier • Formerly known as Social Security Number Removal Initiative (SSNRI) • Direct Mailing to Providers on October 2, 2017 • Consists of a letter/ fact sheet designed to educate Providers • Noridian NMP and listserv information • Transition period – no earlier than April 2018 through December 31, 2019

  10. New Medicare Card • CMS will monitor use of HICNs and MBI’s during this period • Goal to switch to complete MBI by January 2020. • Helpful Websites: • https://med.noridianmedicare.com/web/jeb/search-result/-/view/10546/new-medicare-card-project • https://www.cms.gov/Medicare/New-Medicare-Card/index.html

  11. Targeted Probe and Educate

  12. Targeted Probe and Educate Medicare has moved to a medical review strategy to: • Use data to identify providers to review (Targeted) • Pull smaller sample of claims (Probe) • Provide direct feedback on the results of the probe (Educate)

  13. Targeted Probe and Educate • Process is applicable to JE and JF • Providers are selected for review based on data analysis procedures used by the MAC • Up to three rounds of pre/post pay review will be performed • Sample size up to 40 claims for each round • One-on-one education will be performed after each round is completed • Education may also be initiated during the probe process

  14. Targeted Probe and Educate • Goal is to gain compliance with the Medicare Policy Requirements within the three rounds • If acceptable improvement is not achieved, a referral will be made to CMS • Examples of additional action that may be considered (not an all inclusive list) • Post pay w/extrapolation • Higher levels of prepay review • Referral to the ZPIC/UPIC • Referral to the Recovery Auditor

  15. Targeted Probe and Educate • If selected for review, it does not exclude the provider from other MR activities, for example: • Automated reviews • Comparative billing reports • Mandated demand bill reviews

  16. Targeted Probe and EducateTips for Successful Review • Provider Point of Contact (POC) • Establish a POC for the Noridian Case Manager to work with • Reach out to the Noridian POC as needed • Review the Medicare Policy requirements for the service • The resources are included in the notification letter • Be engaged and participate throughout the review/education process • For webinar education offered, it is okay to include multiple people from your office

  17. Targeted Probe and EducateTips for Successful Review • Additional Documentation Request Letters • Know who receives them/where they go • Know/Track when responses are due back to Noridian • Providers are allowed 45 days to respond • Its better to respond with something versus nothing

  18. Targeted Probe and Educate • Reminder for Lab Providers • MR will continue to reach out to ordering/referring providers when documentation submitted is not sufficient per CMS instruction (IOM100-08 Chapter 3, 3.2.3.7) however providers are encouraged to reach out the ordering/referring to obtain necessary documentation to aid in the review process

  19. Targeted Probe and Educate • Noridian website: • https://med.noridianmedicare.com/ • CMS website: • https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

  20. Comprehensive Error Rate Testing (CERT)

  21. CERT • Program implemented by CMS to measure improper payments in the Medicare Fee-for-Service (FFS) program • CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012

  22. CERT • CERT is a requirement and mandated by law • It is vital that all Medicare service providers are compliant with submitting the necessary information to support the coverage, coding and billing of services being submitted to Medicare for reimbursement • To combat the national CERT improper payment rate, Noridian needs your help…

  23. CERTPrevent Findings! • Comply with request for records from the reviewing entity and other facilities who have performed services for your patients • Ensure Provider Enrollment has the most current address and contact information on file for our practice

  24. CERTPrevent Findings! • Work with ordering/referring providers to ensure adequate documentation can be provided • Implement an internal control/intake process to ensure your practice has the necessary documentation to support services prior to rendering/billing • Assess documentation to ensure orders for plan or intent to order services in medical records (for example, “run labs” or “check blood” by itself does not support intent) are present. Providers need to indicate what specific services are to be done • Note - a requisition alone does not support intent to order

  25. CERTPrevent Findings! • Ensure documentation is legible and properly authenticated • If authentication is questionable, request signature logs be sent with each record request • Code and bill only for the level of service or procedure specified in the medical record • If needed, request clarification from the physician and/or practitioner

  26. Noridian CERT Contacts - Here to Help • Email: CERTQuestion@noridian.com • Provide only the following information in the body of the email: • Provider's name, address, City/State and telephone number • The contact person Noridian will be speaking with in regards to the CERT question • The CID number of the CERT review in question (found on your request for records letter(s)) • NOTE: DO NOT include Protected Health Information (PHI) or sensitive information in the subject line OR in the body of this email

  27. QUESTIONS?

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