Welcome to eSolutions’ Quarterly CMS Update!
CMS changes existing rules and introduces new ones so frequently that it’s hard to keep up! Now you don’t have to – let eSolutions, your Medicare experts, do it for you. You can count on us to inform you of CMS news, changes and new rules on a quarterly basis by subscribing to our blog.
Here Comes PDPM – Are You Ready?
PDPM is only a few weeks away! As of October 1, PDGM will become effective and your skilled nursing facility’s billing processes and revenue cycle will undergo a huge transition. If you need information and tips to help you prepare for PDPM, eSolutions offers these resources and more:
- Webinar: The Ins and Outs of PDPM, Simplified
- The SNF Guide to PDPM: What Every SNF Needs to Know
- PDPM Is Poised to Transform the Way SNFs Do Business – Are You Ready?
Also, please register for eSolutions’ next PDPM webinar at 2 pm Monday, September 23: PDPM and Your Revenue Cycle. Presenter Maureen McCarthy will discuss how to estimate your revenue under PDPM, PDPM transition pitfalls, and what will change with Triple Check and Medicare Meeting.
CMS Set to Phase out CWF Beneficiary Health Insurance Eligibility Transactions (HIQA)
This fall, CMS is expected to migrate Part A provider eligibility inquiries from the Common Working File (CWF) to the HIPAA Eligibility Transaction System (HETS). CMS intends to terminate access to the HIQA, ELGA, ELGH and HIQH eligibility systems. Providers will exclusively use HETS for eligibility transactions following this change.
In December 2012, CMS announced that it would discontinue the Common Working File (CWF) beneficiary health insurance eligibility transactions (MLN Matters® Special Edition Article SE1249). In that same article, CMS also stated that the HIPAA Eligibility Transaction System (HETS) would be the single source for this data going forward. However, CMS subsequently delayed this effort based on feedback about the differences in data returned between the two systems and the one-year limit to HETS historical search capability. CMS has been working to resolve these issues and is now moving forward to phase-out the CWF beneficiary health insurance eligibility transactions.
eSolutions is fully prepared to assist customers in managing the transition to HETS. For all clients running eligibility inquiries from the CWF in eSolutions’ Eligibility, we will be adding the option for you to use HETS for eligibility transactions. Please look for more information coming soon to your inbox regarding changes within eSolutions Eligibility.
QMB System Updates
CMS provides Qualified Medicare Beneficiary (QMB) system updates as part of its ongoing efforts to help providers comply with QMB billing restrictions.
The updates also educate QMBs that they cannot be billed for Medicare deductibles and coinsurance. As implemented through CRs 9911 and 10433, the Common Working File (CWF) identifies that a beneficiary has active QMB status, which results in Remittance Advice (RA) and Medicare Summary Notice (MSN) messages for QMB claims. The RA includes two Alert Remittance Advice Remark Codes (RARCs) that identify an individual currently enrolled in QMB and tells providers they may not collect deductible and coinsurance amounts from these beneficiaries. The Ras contain the QMB RARCs only in conjunction with paid claims generating Claim Adjustment Group Code Patient Responsibility (PR) and Claim Adjustment Reason Codes (CARC) 1, 2, and 66, and report Medicare deductible and coinsurance amounts so that coordination of benefits activities may result using copies of Ras if necessary.
The MSN generated for all QMB individuals includes information regarding their QMB status and lack of liability for Medicare cost-sharing amounts for covered Parts A and B items and services. However, CMS recently determined that the claims processing systems do not differentiate between paid and fully denied claims or denied service lines.
CR 11230 includes the following changes to the claims processing systems to ensure that the MSNs appropriately differentiate between QMB claims that are paid and denied:
- If an MSN includes at least one detail line for a QMB that contains an allowed amount greater than zero, page one (the summary page), will use MSN Message 62.0 to briefly explain the QMB billing protections (in the “Be Informed!” section).
- Also, on page one, the patient’s total liability amount (in the “Total You May Be billed” field) will omit the deductible and coinsurance amounts for details lines that are for a QMB and include an allowed amount greater than zero.
- Further, in the claims detail section of the MSN, if the detail line is for a QMB and includes an allowed amount greater than zero, such detail line will reflect $0 (in the “Maximum You May Be Billed” field) and include message 62.1 that informs the beneficiary of her/his QMB status and billing protections.
Review Choice Demonstration Begins Soon in Ohio
Review Choice Demonstration begins for Ohio home health agencies (HHAs) on Sept. 30, 2019. By September 15, Ohio HHAs had to choose between pre-claim review, post-payment review, or opt-out ant take a 25% payment reduction. Agencies that choose pre-claim review will ultimately have more control over their claims, reimbursement timing and cash flow.
The Centers for Medicare & Medicaid Services (CMS) will continue to post updated information on this website. CMS anticipates 60-90 days between beginning the demonstration in the remaining states of Texas, North Carolina, and Florida. CMS and Palmetto GBA will provide at least 60 days’ notice before the start of the demonstration in each additional state. Providers may send any questions to: homehealthRCD@cms.hhs.gov.
For tips on preparing for RCD, check out our eBook, Getting Ready for Review Choice Demonstration.
Code Set Updates
Your billing staff should be aware of several updates code sets that will be made on October 1, 2019. For details see the following:
Coming in Q4: eMDRs and PDGM
Sign up for eMDRs now
Beginning January 1, 2020, Part A and B Medicare providers can participate in a new CMS program to receive ADR request letters electronically (eMDRs). The sign-up period to participate is open now.
In order to receive eMDRs using eSolutions products, you must designate eSolutions as your CMS Health Information Handler (HIH) the NPPES system.
Here’s the information you need to enter your information into NPPES with eSolutions as your HIH:
- Endpoint Type: “Connect URL”
- Endpoint: https://126.96.36.199:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service
- Endpoint Description: 2.16.840.1.113883.3.1066.1
- Endpoint Use: Other
- Other Endpoint Use: “CMS esMD eMDR”
- Is this Endpoint affiliated with another Organization: Choose “Yes”
- Affiliation: (eSolutions Inc.)
- Endpoint location: 8215 W 108th Terrace, Overland Park, KS 66210
For more information on eMDRs from CMS, check out this article.
If you have any concerns, please contact us at (866) 633-4726. For more details, visit this helpful CMS page.
PDGM Arrives January 1, 2020
By now, you know that the Patient-Driven Groupings Model is coming January 1, 2020. Your home health agency is no doubt making changes throughout your facility in order to play by the new rules. PDGM is expected to present challenges and opportunities for HHAs, as the new rules will drive agencies to better align their operating model with a U.S. healthcare industry that is quickly evolving toward value- rather than volume-based care initiatives.
If you need some last-minute tips or need to get your staff up to speed, eSolutions is proud to offer you these resources:
- Counting Down to PDGM resource page, where you can find links to the latest PDGM news, FAQs, Preparation tips, Behavioral Adjustments FAQs, Intake tips and more.
Don’t forget to sign up for eSolutions’ webinar, “PDGM Changes Impacting the Bottom Line,” at 2 pm, Thursday, October 29. Presenter Karri Wright, senior director of product management at Homecare Homebase, will discuss how PDGM will impact your HHA’s bottom line. She’ll cover admission source and period timing (with elimination of therapy) upcoding; variable LUPA threshold per period instead of episode; responsibly managing comorbidities and primary diagnoses; and other considerations for agencies.