Providers May Need To Re-Enroll To Get Medicare Reimbursements

New Medicare enrollment requirements for medical providers and suppliers may post serious billing issues if applications are not filled out properly and timely.

[amberusa.com]

Section 6401 (a) of the Affordable Care Act established a requirement for all Medicare-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. 

One Kansas health department suffers the consequences of an untimely revalidation application.  The Lawrence-Douglas County health department is currently unable to bill Medicare for healthcare services it provides to seniors.  This self-proclaimed "personnel issue" has already cost the department upwards of $6,000.  

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 Medicare Administrative Contractor (MAC) to do so. Please note that 42 CFR 424.515(d), part of the rules issued by CMS under its rulemaking authority, provides CMS the authority to conduct these off-cycle revalidations.

Same Care, Higher Bill

Medicare Patients Hospitalized but not "Admitted" Can Face Higher Costs

The front page of the Boston Globe yesterday detailed how some hospitals charge Medicare patients different prices depending upon how the hospital classifies their care.  For instance, a patient admitted for "medical observation" receives a much larger bill than one whose stay is classified as "inpatient."  This is true even though the observation patient "usually share rooms with regular inpatients and receive care from the same doctors and nurses, making their status invisible to them."

[voxxi.com]

Although hospitals do not accept blame for these classification differences, the Globe's article showed that hospitals increasingly keep patients in "observation" status longer than the typical 24 to 48 hours.  This can have a startling effect on Medicare billing.

Medicare covers the cost of rehabilitation care in a nursing home if the patient was admitted to a hospital for at least three days of inpatient care.  However, the days that a patient under "observation" do not count toward the three-day minimum needed for Medicare coverage.  As a result, Medicare patients are getting stuck with bills in the thousands, forcing some seniors to file for bankruptcy.

Out of concern for this, Medicare issued regulations this summer they believe will help hospitals clarify this issue. But others, like Toby Edelman, senior policy attorney at the Center for Medicare Advocacy in Washington D.C., believe the regulations do not provide any clarity.  Edleman believes hospitals may be trying to avoid readmission penalties under the ACA for patients readmitted within 30 days of discharge.

New ACA Roll-Outs: Abortion Coverage on the Hill, Medicare House Calls & Colorado Marketplace Rates

As full implementation of the Affordable Care Act approaches, many new programs and state Marketplaces continue to roll out daily.

Taxpayer-Funded Abortion Coverage for Congress

menudoreport.com

An amendment by Iowa Republican Senator Charles E. Grassley requires lawmakers and their staff to obtain coverage through the same insurance Marketplaces that many uninsured Americans will use.  However, many abortion opponents, including Sen. Grassley, worry that this will give members of Congress access to abortion coverage.  Currently, that benefit is denied to members of Congress and all federal employees who receive health insurance through a federal government plan.  Rep. Christopher H. Smith (R-NJ), who authored the abortion-funding ban for federal employee plans, says that requiring Congress to purchase health insurance in the Marketplace would be "a radical deviation and departure from current federal law."


Under the Affordable Care Act, every state must have at least one plan that does not cover abortion.  But the decision as to whether a state must have one plan that provides abortion coverage is left completely up to the individual state. So far, 23 states have barred or restricted abortion coverage in Marketplace plans; 27 states, and the D.C., have no such restrictions.

Medicare Doctors Make House Calls

www.nytimes.com

Under an ACA program called "Independence at Home," the Centers for Medicare and Medicaid Services contracted with 20 providers or provider groups nationwide to incentivize primary care providers who accept Medicare payments to make house calls to "medically complex patients."  The goal of the program is to improve quality of care and prevent future, more expensive treatments by encouraging doctors to invest in their Medicare patients up front.  The ACA authorizes expanding the program if this goal is met -- if quality of care improves at the same or lower cost and with the same or better outcomes.

Colorado Releases Marketplace Insurance Rates

Colorado's Division of Insurance released next year's rates under the ACA.  Colorado's Marketplace will house a whopping 18 different insurers providing 541 different plans for both individuals and small businesses.  The Denver Business Journal reported that these rates prove Colorado will not experience "rate shock," meaning consumers will likely not see higher sticker prices on the state's Marketplace than they do for presently available insurance options.  Like many states, the rates will depend on the region in Colorado where the customer lives.