Medicare Revalidations

Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted. Between now and March 23, 2015, MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier. Providers and suppliers must wait to submit the revalidation only after being asked by their MAC to do so. Please note that 42 CFR 424.515(d) provides CMS the authority to conduct these off-cycle revalidations.

ICD-10 countdown: What’s your contingency plan?

Author Name Jennifer Bresnick | Date September 4, 2013

We all hope the question won’t be necessary, but the industry-wide climate of fear and dread that has surrounded ICD-10 demands an answer. What will you do if you or one of your major business partners crashes and burns on October 1, 2014? Experts are starting to nudge providers into considering the worst even as they plan for success as it becomes clear that a lack of coordination and slow progress 0on the part of vendors and payers is putting the hopes of a smooth transition in jeopardy.

Pinpoint your weak links

Contingency planning depends on knowing where your trouble spots lie so you can address them appropriately. “Maybe one of the vendors went out of business. Or maybe you never approached all of your payers,” says Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS, Senior Director of HIM Innovation for Nuance. “It’s like business disaster planning. If one of those is out of alignment, it can disrupt your whole plan. Business partners, business associate agreements, IT vendors, contracts…all of those things need to be built in and accounted for in your contingency plan.”

“You internal systems might fail. Your vendor software might not be delivered on time. Your health plans might not be ready. You just need to identify all those risks and look at how you can accommodate that with internal efforts,” adds Jim Daley, Director of IT Risk and Compliance at BlueCross BlueShield of South Carolina and the Chairman of WEDI. Contacting your partners to figure out where they are in the software development, internal testing, or customer preparation process is vital to ensuring that you can cover all your bases.

Build your safety net

“Would you need extra staff? Are there alternative services you can use if one of your partners isn’t ready? If a payer isn’t ready, do you have cash reserves so you can handle a short term shortfall in payments while the payer is getting ready?” Daley asks. “Certainly we hope that any disruption is minor and short term, but you never know with something this large.”

External testing is recommended as the best way to ensure that claims are formatted properly and can be transmitted and received by payers. But participating in testing is fraught with difficulties that few organizations seem ready to tackle. “Many of the large health plans should be ready to test by the first quarter of 2014…or at least that’s what they’re saying publically. But it’s not just a question of reworking their software to accept a different length of diagnostic code,” explains Robert Tennant, MA, Senior Policy Advisor at the Medical Group Management Association (MGMA). All their payment policies must be examined and rewritten to accommodate the changes in the codes. I think that has proven to be more challenging than many had anticipated.”

Participating in a testing exchange or relying on your EHR vendor to forge the way may work for some customers. But most providers, especially smaller physician offices, will need to go it alone. Thorough physician and coder education, as much external testing as possible, and good communication with vendors, payers, and clearinghouses will certainly help, because…

The best defense is a good offence

“Instead of looking at contingency, look at what you can do to avoid that being necessary. What can you do to get ready? That’s the best way to avoid all the risks,” encourages Daley. “That’s the number one message. Get started and push forward to do everything you can.”

“First and foremost, make sure that you have obtained the education for clinical coding needed to support your practice,” suggests Mike Denison Senior Director of Strategic Projects at Emdeon. “Everyone is familiar with their ICD-9 world that they live in now, but ICD-10 is vastly different. We’re recommending that each billing manager or person submitting the claim obtains the education required to code appropriately.”

“Secondly, make sure you’re working with your vendors to ensure that they have the capability to enable testing, or they have the ability to at least dual code ahead of the compliance date so you’re practicing your coding,” Denison continues. “That’s going to be really important in order to get acclimated to coding ICD-10, so you can become aware of what it’s going to be like come the compliance date.”

“You should really look at your specialties, your physician population, and your patient population to see what you need to focus on,” Cassidy states. “You have to get laser focused on your own patient population so you know what your top 25 DRG codes are, and you know what’s missing in your education and documentation.

“You already know what areas are going to be important to you. If you had to switch to ICD-10 today, you can predict where the trouble spots will be.”