Wilhide Consulting: January 2015

Wednesday, January 14, 2015

MedPAC once again recommends SNF payment reform

MedPAC report here:

MedPAC Report

Conclusion
The many changes made to the payment system have done little to address the shortcomings of Medicare’s payment system for skilled nursing facilities that were identified soon after the system was implemented. The present payment system continues to encourage providers to furnish clinically-unnecessary services for financial gain. With a number of providers experimenting with various payment reform models, accuracy should remain a central concern since bundled payment and ACO reforms continue to rely on fee-for-service payments. Without changes to the prospective payment system, skilled nursing facilities will continue to have incentive to furnish care that runs counter to broader reforms. Our results confirm that changes more sweeping than those made to date are required. A revised payment system would improve the accuracy of payments to skilled nursing facilities, make providers more neutral to the types of patients they admit, and dampen the incentive to furnish therapy services unrelated to patients’ care needs.

Monday, January 12, 2015

Instructions for NOMNC and DENC have been updated. FORMS HAVEN'T CHANGED

From Judy: They posted the updated instructions on both pages: The PPS Page and the MA Plan page. We've been using the same form for both for a couple of years now. NOTE: We all changed our QIO phone numbers last summer. Those numbers are on the 'resources' section of my website. I read the instructions, and see no substantive policy changes, but read them yourself. I may have missed something.

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFSEDNotices.html

January, 2015: New NOMNC and DENC form instructions available below, in 'Downloads'. Neither the NOMNC or the DENC form has changed, and providers may continue using the current forms.

Full instructions on the Original Medicare, also known as Fee for Service (FFS), expedited determination process are available in Section 260, of Chapter 30 of the CMS Claims Processing Manual, available below in 'Related Links'.

To download the FFS Expedited Determination Notices and Instructions (the NOMNC and DENC), please click on the appropriate link below.

Downloads

Related Links

Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) [PDF, 426KB]

CMS Transmittal revising timeframes for submitting ADRs has been revised, one more time.

New Timeframe for Response to Additional Documentation Requests

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R566PI.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf

3.2.3.2 - Time - Frames for Submission

(Rev. 566, Issued: 01-07-15, Effective: 04-01-15, Implementation: 04-06-15)

This section applies to MACs, RACs, CERT, and ZPICs, as indicated.

A. Prepayment Review Time Frames

When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.

B. Postpayment Review Time Frames

When requesting documentation for postpayment review, the MAC, CERT and RAC shall notify providers that the requested documents are to be submitted within 45 calendar days of the request. ZPICS shall notify providers that requested documents are to be submitted within 30 calendar days of the request. Because there are no statutory provisions requiring that postpayment review of the documentation be completed within a certain timeframe, MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of submission extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.