When the COVID-19 public health emergency (PHE) began, this consultant, like most of the US population, ceased traveling and conducted all reimbursement education and consulting virtually. Because traveling is very time-consuming, this consultant decided to use newfound time to investigate all of the reimbursement resources that the CMS and the Medicare Administrative Contractors (MACs) make available to professionals and providers who manage wounds and ulcers for Medicare beneficiaries. Because this 18-month investigation has been an amazing "eye-opener" for this consultant, this column was created to share the excellent resources that readers may want to incorporate into their businesses.
THE CMS "TELLS" THE REIMBURSEMENT REGULATIONS
The CMS is very transparent about the reimbursement regulations that pertain to various sites of care, professionals, and suppliers. All of the reimbursement regulations are posted and clearly categorized on the CMS website.1
At the bottom of the homepage, anyone can register to receive CMS email updates about topics that pertain to their business. The CMS updates are always prompt and informational. For example, when the CMS released the 2022 final payment rules for the physicians/QHPs and hospital-owned outpatient wound/ulcer management provider-based departments, they sent email updates and fact sheets that same day. The CMS website also supplies the National Correct Coding Initiative Policy Manual2 and Procedure-to-Procedure coding edit files3 for procedures/services that are components of other procedures/services. The manual and files supply the answer to the question that wound/ulcer management professionals ask nearly every week: "Will Medicare pay for both of these procedures if I perform them during the same encounter?"
The CMS also holds many open-door forums. During the forums, the CMS updates participants about new/changed regulations, carefully listens to suggestions, and willingly answers questions. In fact, during the COVID-19 PHE, this consultant listened to one or more open-door forums every week. The CMS responded to the unforeseen PHE-created hurdles by releasing hundreds of waivers that allowed wound/ulcer management professionals to supply care to beneficiaries in their homes via telehealth, phone calls, and so on. All of the waivers were posted as quickly as they were created and discussed in the next open-door forum. This consultant highly recommends assigning someone in your business to take part in these forums and to report the learnings to your entire team.
The Medicare Learning Network4 is another fabulous website that supplies free educational materials for healthcare professionals/providers about CMS programs, policies, and initiatives. Just like the CMS website, you can register to receive notice of new releases, which are posted every Thursday. For example, you will find excellent booklets and fact sheets about evaluation and management, the hospital outpatient prospective payment system, documentation and signature requirements, Medicare billing for outpatient physical therapy, critical access hospital billing, telehealth services, Advance Beneficiary Notices of Non-Coverage, and much more.
THE MACS "TEACH" THE REIMBURSEMENT REGULATIONS
Once the CMS releases and posts reimbursement regulations, the MACs quickly implement them. Each MAC's website supplies a plethora of information such as Medicare fee schedules, local coverage determinations, local coding articles, and medical review focus topics and findings.
This consultant was impressed with the useful tools that the MACs created: documentation checklists that show all of the information that should be in medical records, modifier lookup tools, medically unlikely edit tools, and various calculators. The MACs even teach how to use the Local Coverage Reconsideration Process to request refinements to existing coverage policies. And finally, anyone can subscribe to receive email updates from their MAC. This consultant is subscribed to all of the MACs' email updates, which help keep track of reimbursement changes throughout the country.
The MACs go out of their way to supply education to the professionals and providers in their jurisdictions. Throughout the COVID-19 PHE, this consultant took part in several hundred educational programs provided by every MAC in the country. These programs covered nearly every reimbursement question that this consultant regularly receives. As an added bonus, the MACs provide participants with the slides from each program. Following are the major types of educational programs that are offered by the MACs:
* The scheduled "Ask the Contractor" calls offer participants the opportunity to ask questions and receive immediate answers about reimbursement process issues.
* Weekly webinars are announced in advance to allow professionals and providers to register and set aside time on their calendar to listen and take part in the live question-and-answer portion.
* To accommodate busy schedules, many of the webinars that pertain to physicians/QHPs are offered as "after-hours" webinars.
The MACs also supply many "on-demand" educational tutorials. For example, if you want to learn how to use an Advance Beneficiary Notice of Non-Coverage, watch the tutorial. Some are even on Facebook and YouTube! This consultant took many of the "on-demand" tutorials and found them highly informative and useful. Most important, they cover topics that wound/ulcer management professionals and providers consistently do not understand.
When the MACs find errors that consistently cause claim denials or repayments, they typically offer one or more educational programs that pertain to those specific topics. Keep in mind that the MACs prefer to process claims that are coded correctly and supported by documentation that "paints the picture" of the medical necessity, with a complete description of the services, procedures, and products reported on the claims.
Because the MACs are required to conduct Targeted Probe and Educate audits, each MAC has a webpage that thoroughly instructs those interested on how to successfully pass the audit. The CMS also audits each MAC's claim processing accuracy. Because the MACs want to achieve good ratings, they share the results of their audits; they want professionals and providers to learn about the claim processing errors for which the MACs must collect repayments.
"TESTING" REIMBURSEMENT COMPLIANCE
Because the Medicare Trust Fund has a finite amount of money, the CMS and the MACs are mandated to test reimbursement compliance. There are many layers of compliance audits. In some cases, a wound/ulcer management professional or provider will be randomly picked for an audit. In other cases, something in the professionals' or provider's coding and billing practices may cause them to be selected. In all cases, this consultant genuinely believes that getting paid correctly and preventing repayments and fines are totally in the control of professionals and providers.
The MACs and other auditing contractors even post what they are going to audit. Therefore, wound/ulcer management professionals and providers should conduct internal audits accordingly, which should catch and correct errors before the external auditors find them. In addition, wound/ulcer management professionals and providers should make a monthly habit of printing and personally reading several of their patients' medical records. Verify that the printed medical record meets all the CMS and MAC requirements. This is important because most professionals and providers use electronic medical records, but they do not always consider how each screen connects to the next and if the completed record really "paints the picture" of each separate patient encounter.
The moment professionals and providers learn that they are being audited, they should verify the type of audit (Table), the documentation requested, and the exact submission due date. If professionals and providers are not sure what the auditors are requesting, contact them before gathering the medical records. Most important: do not miss the submission due date; if the auditors do not receive any information from the professionals and providers, or if the information does not arrive by the due date, you will fail the audit.
Summary
After 18 months of reading all the pertinent reimbursement regulations that the CMS "tells" us, after taking advantage of hundreds of programs that the MACs "teach," and after reviewing how the various contractors "test" for compliance, this consultant is certain that the CMS and the MACs are providing the necessary information and tools for reimbursement success. It is up to professionals and providers to take advantage of what the CMS and MACs tell, teach, and test. Then they will be totally in control of receiving proper payment for their excellent work and retaining their payment after an audit.
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