Tag: revalidation

Prior Authorization Pilot Program – Status Update

Written by David Werfel on May 12, 2016. Posted in Medicare, Member Advisories, Member-Only.

CMS released preliminary data on the impact of the prior authorization demonstration program on Medicare payments for ambulance services. This data is limited to the three states (NJ, PA, and SC) that were included in the demonstration program’s first year.

CMS noted that it has observed a dramatic decrease in expenditures for repetitive non-emergency ambulance transports since the program’s implementation. CMS released the following data for the first 10 months of the program (i.e. December 2014 – September 2015), comparing that data to the first 11 months of 2014:

Payments for repetitive non-emergency ambulance transportation in these states averaged $5.4 million per month, down from nearly $18.9 million per month prior to the program’s implementation. This is a reduction of more than 70%.
In the states that were not part of the demonstration program, payments have decreased very slightly for the 10 months in 2014 and are very similar to the payments in the 11 months prior to the program beginning in SC, NJ and PA.
18,367 prior authorization requests were received and finalized by Medicare’s contractors. Of these, 6,430 (35.0%) were approved.

CMS is closely monitoring these results to evaluate its effectiveness. Here is the full status update.

CMS Implements Cycle 2 Revalidation Program

Written by Brian Werfel on April 22, 2016. Posted in Government Affairs, Medicaid, Medicare, Regulatory, Reimbursement.

By Brian S. Werfel, Esq. AAA Medicare Consultant

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CMS recently announced the start of its Cycle 2 Revalidation Program. This program affects all enrolled Medicare providers and suppliers.

In Cycle 1, which was conducted from 2011 through 2015, the so-called “trigger” to revalidate was a formal request to do so by your Medicare Administrative Contractor (MAC). For Cycle 2, CMS is adopting a new approach. CMS will be assigning revalidation due dates, i.e., dates by which the provider or supplier must revalidate. These due dates will be the last day of a particular calendar month. These due dates are based on the provider’s or supplier’s last successful revalidation or the date of the provider’s or supplier’s initial enrollment with Medicare. In other words, providers or suppliers that last revalidated in 2011 are likely to have new revalidation due dates in 2016, providers or suppliers that revalidated in 2012 are likely to have 2017 due dates, etc. The first set of due dates is May 31, 2016.

CMS has indicated that it will notify providers or suppliers by email within 2-3 months of their due date. These emails will include the following subject line: Urgent: Medicare Provider Enrollment Revalidation Request. If the email is returned as undeliverable, the MAC is instructed to send a paper revalidation notice to at least two of your reported addresses: correspondence address, special payments address, or primary practice address.

Providers or suppliers will be permitted to submit revalidations up to 6 months prior to their scheduled due date. Revalidations can be submitted either on paper or by using the online Provider Enrollment, Chain, and Ownership System (PECOS).

If a provider or supplier fails to submit a timely revalidation packet, CMS has indicated that the entity’s Medicare billing privileges will be deactivated. The entity will be required to submit a complete enrollment application to “reactive” its billing privileges. However, CMS has indicated that no payments will be made for services provided during the interim period.

If you have not received an email from your MAC asking that you revalidate, it is likely that your revalidation due date is more than 3 months out, or has not even been assigned. However, it is possible that the requests to revalidate may have been sent to invalid email addresses, or may have been routed to your email “spam” folder. It is also possible that paper revalidation notices may have been sent to obsolete physical addresses.

For these reasons, the AAA is strongly encouraging members to check the CMS revalidation webpage. That webpage includes a lookup tool that you can use to determine whether your organization has been assigned a revalidation due date. Currently, CMS has assigned due dates through the end of October 2016. Providers and suppliers that have yet to be assigned due dates will display as “TBD”. You can also download the entire list of currently enrolled providers and suppliers into an Excel spreadsheet. This option may be particularly helpful for organizations that bill under multiple Medicare PTANs (which can have separate revalidation due dates) and for billing agents that intend to assist their clients with the revalidation process.

In sum, the new process appears to be a vast improvement over how revalidations were handled during Cycle 2. Assuming things work as intended, AAA members should have a minimum of 2 months prior notice of the need to revalidate, and potentially up to 6 months prior notice. This should be more than enough time to submit the revalidation and avoid any potential disruptions to your ability to bill Medicare.

Medicare Revalidations: Will CMS Get Cycle 2 right?

Written by Brian Werfel on April 4, 2016. Posted in Medicare, Reimbursement.

The Affordable Care Act imposed a new set of screening and enrollment requirements for participation in the Medicare, Medicaid, and CHIP programs. These included additional screening criteria, new disclosures, an enhanced period of oversight for newly enrolled providers and suppliers, and the payment of a new enrollment fee ($554 in 2016). To implement these new requirements, CMS was required to revalidate all existing Medicare providers and suppliers between 2011 and 2015. CMS referred to this first 5-year revalidation period as “Cycle 1.”

As many of you will no doubt recall, Cycle 1 did not go as smoothly as the provider/supplier community (or CMS) had hoped. Looking back, it seems reasonable to conclude that the initial revalidation cycle put the Medicare Administrative Contractors in an impossible situation. The MACs were required, on relatively short notice, to develop policies and procedures that would hopefully permit the thousands of enrolled Medicare providers and suppliers in their jurisdictions to revalidate enrollment information on a relatively compressed time-scale.

The procedure adopted by most of the MACs was to instruct providers and suppliers not to revalidate unless and until instructed to do so by the MAC. Upon receipt of a revalidation request, the provider or supplier would then have sixty (60) days to gather up the required information and submit it to MAC for review. While seemingly reasonable in theory, this procedure proved to be a disaster in practice.

The problem, in a nutshell, was that the MACs (and the Carriers and Fiscal Intermediaries before them) had largely ignored the existing requirements related to revalidation. The enrollment information these MACs had on file for many ambulance suppliers was outdated. For example, the ambulance supplier may have moved its base of operations during the previous decade, but, for whatever reason, neglected to notify its MAC of this address change. As a result, the request to revalidate would end up being sent to an invalid address. In many cases, an ambulance supplier would tell us that the first indication they had that their MAC wanted them to revalidate was the discovery that their provider number had been suspended. When they would contact their MAC to inquire as to why, they would be told that they had failed to revalidate within the required timeframe. In many cases, it was weeks or months before these problems could be rectified, and the provider’s or supplier’s billing number reinstated.

Even if the provider or supplier received the revalidation request, other problems could easily arise.

Many providers or suppliers submitted their revalidation submissions on paper, only to discover the MAC failed to register their receipt. Other times, the MAC would confuse the submission with the name of a similar sounding ambulance provider. Minor mistakes on the enrollment form would lead to a prolonged series of requests for additional information, etc. The end result was endless hours spent on what was intended to be a simple formality.

In sum, Cycle 1 would charitably be described as a difficult time for ambulance providers and suppliers. The question that remained to be answered was whether CMS would learn from its mistakes and change the process the next time around, or whether it would continue the existing process despite its known limitations?

Well, CMS recently published its plans for the second 5-year cycle of revalidations (creatively titled “Cycle 2”), and a preliminary review suggests that CMS has made numerous improvements to the process.

[quote_right]Your organization’s obligation to revalidate will no longer be based on a written request from your MAC. Instead, CMS will assign a due date by which each and every enrolled provider or supplier must revalidate.[/quote_right]The most significant change is to the trigger for each provider’s or supplier’s obligation to revalidate. Your organization’s obligation to revalidate will no longer be based on a written request from your MAC. Instead, CMS will assign a due date by which each and every enrolled provider or supplier must revalidate. This due date will always be the last day of a calendar month (e.g., June 30, 2016, July 31, 2016, etc.). CMS indicated that your assigned due date will likely stay the same though subsequent review cycles.

Beginning March 1, 2016, CMS will make available a listing off all currently enrolled providers and suppliers (excepting DME suppliers). Ambulance organizations due for revalidation within 6 months will display a due date. All other ambulance providers and suppliers will show a “TBD” (To Be Determined) in the due date field.

The list of currently enrolled providers/suppliers can be obtained here. On that same webpage is a searchable tool that permits you to look up your organization by its name and/or NPI. The MAC will also send a revalidation notice via email or regular mail within 2-3 months of a provider’s or supplier’s revalidation due date.

CMS will accept revalidation submissions up to six months prior to an organization’s due date. CMS further indicated that “unsolicited revalidations” (defined to be revalidation applications submitted more than six months prior to the provider’s or supplier’s due date) will be rejected.

As in the past, revalidations can be submitted either on paper using the CMS-855 form or through the Provider Enrollment, Chain, and Ownership System (PECOS).

The other significant change to the process involves situations where the provider or supplier failed to revalidate in a timely fashion. During Cycle 1, this failure would result in the deactivation of the ambulance service’s PTAN. However, the MAC would typically permit you to submit a corrective action plan (i.e., a completed revalidation), and upon its approval, reinstate your billing privileges retroactively back to the date of suspension. However, for Cycle 2, CMS is indicating that if your PTAN is deactivated, you will be required to complete a new enrollment application. While you will ultimately have your PTAN reactivated, the effective date of that reactivation will be the date you submitted a new and complete application. You will not be able to submit claims to Medicare for dates of service that occurred during the resultant gap in coverage.

The new process appears to be a vast improvement over Cycle 1. Assuming everything works as intended (always a big if when CMS and its MACs are involved), ambulance organizations should have more than adequate notice of their revalidation due date. While I would suggest checking the CMS list monthly, even quarterly checks would give a provider at least 90 days to submit the revalidation request. Compared to the theoretical 60 days provided during Cycle 1 (which, in many instances, shrank to 30 days by the time the notices were actually received by the provider or supplier), this is a vast improvement.

In the past, it was convenient to blame the failure to submit these revalidations in a timely fashion on the bureaucratic inefficiency of your MAC. Under the new process, we should have more than adequate notice, meaning any failure to revalidate is likely to be our own fault.

Which leads me to my final suggestion for getting through the Cycle 2 revalidation process without any major problems….

GET YOUR REVALIDATION IN ON TIME!

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.