Medicare Billing and Dual Eligible Populations · Medicare Advantage network needs •Diabetes Prevention Program –New Medicare Part B benefit effective April 1, 2018 –Many MA

Medicare Billing and Dual Eligible Populations

Timothy P. McNeill, RN, MPH

Medicare Provider Application Process

Implications of being a Medicare Provider

Billing for Dual Eligible Beneficiaries

Q & A4

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What Does Medicare Cover?

• Part A: Medicare Part A covers inpatient hospital care, skilled nursing facility care, home health services, and hospice.

• Part B: Medicare Part B covers physician services, office visits, screenings, therapies, preventive services, outpatient services, emergency care, ambulance services, medical supplies and durable medical equipment.

• Part C: Medicare Part C is the private health insurance option for Medicare beneficiaries. Medicare Part C is often referred to as Medicare Advantage.

• Part D: Medicare Part D is the prescription drug benefit option.

What are the types of Medicare Providers?

• Organizations can become a Medicare Provider as long as they can provide at least one (1) Medicare service– Exception: The one service cannot be DSMT

• Medical Nutrition Therapy is an acceptable service to obtain a Medicare provider number– The Organization will submit as a “Group Practice”– The dietitian will be the provider linked to the Group Practice

application– Additional services can be provided based on additional provider

types obtained (e.g. LCSW- Therapy, Nurse Practitioner

Services that AAAs are providing

• Direct Provider Services– Medical Nutrition Therapy (MNT)– Diabetes Self-Management Treatment (DSMT)– Diabetes Prevention Program (DPP)– Psycotherapy / Counseling

• Contracted Services as a third-party case management entity– Transitional Care Management (TCM)– Chronic Care Management (CCM)– Collaborative Care Management (CoCM)

What is the Medicare Provider Application Process?

• Medicare provider applications are submitted to your MAC

• MAC: Medicare Administrative Contractor– Process Medicare FFS claims – Enroll providers in the Medicare FFS program– Review medical records– Respond to provider inquiries– Find your MAC at this address:

• https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html

Application Forms

• 855B -http://www.cms.gov/Medicare/CMS=Forms/CMS=Forms/downloads/cms855b.pdf

• 855i -http://www.cms.gov/Medicare/CMS=Forms/CMS=Forms/downloads/cms855i.pdf

• 855R -http://www.cms.gov/Medicare/CMS=Forms/CMS=Forms/downloads/cms855r.pdf

• 588 - http://www.cms.gov/apps/files/aco/cms588.pdf

Form Completion Process

• Complete forms simultaneously• The Primary application is the 855B• Submit completed application forms to the MAC using

the PECOS system• PECOS

– Internet-Based Provider Enrollment, Chain and Ownership System

– Faster than paper-based enrollment– Available at: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

Ownership Interest

• All Medicare Provider applicants must disclose each member that has control of the organization– Board Members for a Non-Profit– Each person must sign a form stating that they have No

Adverse Legal Action History that prevents their participation

– Liability is shared when fraud occurs

Additional Forms

• CMS Form 588: Authorization for Electronic Funds Transfer

• CMS Form 855i: Registers the provider with Medicare• CMS Form 855R: Authorizes CMS to pay the

organization for professional services rendered by the independent provider

Key Terms

• PTAN – Provider Transaction Access Number• NPI – National Provider Identification • MAC – Medicare Administrative Contractor• DSMT – Diabetes Self-Management Treatment

– Accreditation

Medigap Market

• Medicare Part B beneficiaries can purchase a Medigap or supplemental policy to cover the 20% coinsurance requirements

• A Medigap policy defined• Health insurance sold by private insurance companies to

fill gaps in Original Medicare coverage• Coinsurance, copayments, deductibles• If a beneficiary elects Medicare Advantage, they cannot

be sold or use a Medigap policy• Beneficiaries with Medicaid (Duals) generally cannot

buy a Medigap policy

Medicare Advantage

• Medicare Part C• Required to cover all Part A and Part B benefits• Providers must be credentialed as a network provider for

the Part C plan• Network providers can submit claims for reimbursement

DSMT Services

• DSMT services require accreditation• Proof of accreditation must be submitted to the MAC• Organization obtains Diabetes Self-Management

Education and Support (DSMES) accreditation– American Association of Diabetes Educators (AADE)– American Diabetes Association (ADA)

• Accreditation will be issued to the organization• Organization must obtain a separate certificate that lists

the RD along with the organization• Most MA plans require accreditation

DSMT Accreditation

• SMRC is a curriculum model that can complete the accreditation process

• Requires clinical supervision• Medicare requires a RD for reimbursement• MNT reimbursement pays 85% of the allowable rate for

services rendered by a RD• Accreditation certificate example

– Anywhere USA AAA / Jane Doe, RD, MA

Medicare Advantage Credentialing

• Credentialing is the process of reviewing and verifying documentation of clinical providers for participation in a health plan as a provider

• The organization and all providers linked with the organization must complete the credentialing process

• Medicare vs Medicare Advantage– A multi-payer strategy would include enrollment with

Medicare and credentialing with the leading MA plans in a market

– Credentialing is not linked to Medicare provider enrollment

Medicare Advantage network needs

• Diabetes Prevention Program– New Medicare Part B benefit effective April 1, 2018– Many MA plans have limited or no coverage for Diabetes

Prevention– DPP is a Part B benefit so MA plans must find providers to

cover this benefit– Potential Strategy

• Enroll to be a provider of comprehensive diabetes solutions

– DSMT– MNT– DPP

CMS Rule Changes for Medicare Advantage Plans

• CMS Announced Medicare Advantage Plan requirement changes to increase plan flexibility to tailor services to the needs of the beneficiary:– Proposed Ruling released in two parts

• December 27, 2017• February 1, 2018

– Final Policy Released• April 2, 2018

– CMS Guidance Memo Released• April 27, 2018

2019: Expanding Health Related Supplemental Benefits

• The previous regulations limited supplemental MA plan benefits to health-related services. – There were specific limitations on supplemental benefits that

include daily maintenance.

• This requirement prevented some plans for designing supplemental benefit packages that included non-skilled services that could reduce readmissions or improve health outcomes.

2019 Re-interpretation of the Supplemental Benefit

– “Under this reinterpretation, CMS would allow supplemental benefits if they are used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

Uniformity Flexibility

• There was a rule that required health plan benefits to be made available to all beneficiaries uniformly

• Some plans would not develop targeted benefits for specific population because of fear of violating this rule.

• The 2019 rule change:– CMS has determined that plans can provide certain enrollees

with access to different benefits and services.

Bipartisan Budget Act of 2018

• Signed into law• Includes the Chronic Care Act• Changes required by the Bipartisan Budget Act of 2018

take effect beginning 2020, and subsequent plan years

Excerpt from Legislation

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• For plan year 2020 and subsequent plan years, in addition to any supplemental health care benefits otherwise provided under this paragraph, an MA plan, including a specialized MA plan for special needs individuals (as defined in section 1859(b)(6)), may provide supplemental benefits described in clause (ii) to a chronically ill enrollee (as defined in clause (iii)).

CMS Guidance Memo Released

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• April 27, 2018: CMS released guidance on services that can be included as a supplemental benefit. Key categories include:– Adult Day Care Services– In-Home Support Services– Support for Caregivers of Enrollees– Stand-alone Memory Fitness Benefit– Home & Bathroom Safety Devices & Modifications– Transportation

Application in your Market

• Conduct a market analysis– MA Plans– Special Needs Plans– Providers / Health Systems serving MA plan/SNP members– MLTSS / D-SNP requirements

• Medicaid Managed Care Plans

• Assess your competition• Define your value proposition• Know the decision triggers for your customer

– Cost Avoidance– Improved Quality (HEDIS)

Assessing Your Market for MA Plan Penetration

• Medicare Advantage Plan data is publicly available at the County level– https://www.cms.gov/Research-Statistics-Data-and-

Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/index.html?redirect=/MCRAdvPartDEnrolData/01_Overview.asp#TopOfPage

Market Analysis for MA Plan Penetration

Monthly Enrollment by State/County/Contract

Enrollment by County By Plan (Birmingham, AL)

Medicare Number and Liability

• Submitting Medicare claims for services opens an organization to legal and financial liability

• You must obtain proper insurance coverage to protect against potential liability– Professional liability insurance– Cyber Insurance

• Liability coverage does not protect against fraud

CBO Example #1

• Anywhere USA AAA• The AAA successfully completed DSMT accreditation• After their experience with CCTP they discovered that

there was an unmet need for counseling for persons with chronic depression

• The AAA obtained a Medicare provider number and now they provide DSMT/MNT and counseling services for Medicare beneficiaries– All three services are billed to Medicare– Clinical Integration Strategy with healthcare providers

CBO Example #1

• Anywhere USA AAA• The AAA successfully completed DSMT accreditation• After their experience with CCTP they discovered that

there was an unmet need for counseling for persons with chronic depression

• The AAA obtained a Medicare provider number and now they provide DSMT/MNT and counseling services for Medicare beneficiaries– All three services are billed to Medicare– Clinical Integration Strategy with healthcare providers

Medicare Providers and Alternative Payment Models

• The Medicare Access and CHIP Reauthorization Act (MACRA) will expand provider participation in Alternative Payment Models (APMs)

• Two primary APMs include the following:– Accountable Care Organizations– Bundled Payment

• APMs provide an opportunity for Gainsharing and shared savings participation

• Gainsharing requires having a Medicare provider number to participate

Clinical Integration

• A clinical integration strategy is essential for long-term success

• Clinical integration links the programs and interest of the AAA with the services and interest of key healthcare partners

• Establishes clinical pathways that results in referrals to AAA programs– Referrals– Order for AAA services– Services linked to reimbursement for long-term sustainability– Bidirectional data exchange to document outcomes

Dual Eligible Beneficiaries

• Duals are persons with both Medicare & Medicaid• Commonly referred to as a Dual Eligible or a Medi-Medi• Medicaid is required to pay the co-insurance and deductibles

for Duals• Provider must first bill Medicare and then bill Medicaid for the

second portion

Coverage for Dual Eligible Beneficiaries

• Participate in Medicare VBP program models• Duals hold the greatest financial risk in a VBP contract• Duals Eligible beneficiaries have Medicaid as the

Medigap coverage policy• Medicaid must cover the co-insurance, even if the service

is not a current Medicaid covered benefit in that particular State.

Questions

• Tim McNeill, RN, MPH– Email: [email protected]