Updated on: November 28, 2016

Dear Doctor: We Don’t Care if You Don’t Get Paid Promptly

Original story posted on: February 22, 2016

EDITOR’S NOTE: The following is a personal reflection by the author and does not necessarily reflect the views of the Healthcare Billing and Management Association of which she is president.

The story I am going to relate in this article could borrow a line from the classic 1989 comedy “When Harry Met Sally.” In the film, Sally is sobbing, noting that she is about to turn 40. When Harry asks when, Sally responds, “someday!”

There has been so much talk about how smoothly ICD-10 implementation has gone. There were no big surprises, no significant increases in claim denials, and cash flow was not significantly disrupted. But wait! Let’s talk about the forthcoming Centers for Medicare & Medicaid Services (CMS) announcement about just one national coverage decision that was an absolute disaster. This is not an isolated problem, but the best example I know of how bad it can get, how quickly it can snowball, and how long providers are expected to just wait for payments.

On Feb. 5, 2015 CMS issued a national coverage determination (NCD) for screening for lung cancer with low-dose computed tomography (LDCT). There is no doubt that this was a very good decision. However, at that time, CMS did not provide any instructions regarding CPT, HCPCS, or diagnosis codes that would be covered under this policy – or any methodology to bill for the services. That would be released “someday.” In spite of pressure from numerous organizations, the HCPCS code was not released until the 2016 fee schedule was published in the final quarter of 2015. The date providers could begin billing the code was Jan. 1, 2016. It was bad enough to wait almost a full year to bill for all the legitimate, medically necessary services provided to Medicare beneficiaries, but the other shoe was about to drop. 

For those not in the radiology industry, the policy covers people who smoked in the past or who are current smokers, as long as other specified criteria are met. When the covered diagnosis codes in ICD-9 and ICD-10 were published in October, it was immediately obvious that CMS had completely omitted the diagnosis codes for current smokers (See MM9246). In spite of the fact that this error was brought to the attention of CMS, and the agency agreed that there was a significant omission, it responded that it would be addressed at the earliest convenience. This omission was incorporated in the applicable Medicare manuals, NCDs, and other transmittals and instructions. 

Communications with CMS over the past week have resulted in the promise of a forthcoming transmittal that will explain how and when corrections will be made. Because NCDs are only updated quarterly and because CMS already was working on the quarterly updates well into 2016, the earliest we can expect corrections for claims is in the July 2016 publication, possibly to be implemented in October. Ladies and gentlemen, that is one full year plus either five or eight months before any correct adjudication will begin. Will claims need to be resubmitted, or will they be reprocessed? There will need to be overrides for timely filing and other operational realities. Will the providers also have to bear that burden?

No one expected CMS to implement the myriad changes required by ICD-10 error-free. Mistakes happen. But this system is broken and it needs to be fixed. Once a coverage decision has been made, the mechanism for submitting claims and receiving correct payment should be in place before issuing notices. Holding claims for 11 months is not OK. Correction of egregious (or even minor) errors certainly should not take six months or longer. Prompt interim instructions should be implemented to allow for claims submission and correct adjudication and payment as soon as the error is known. 

It seems to me that we have a double standard. When a Medicare contractor wants something, there is a very short timeline in which to respond or suffer the consequences. When CMS has errors, there is apparently no clock for resolution or concern for the providers that cannot get paid for treating Medicare beneficiaries.

In this case, we can expect payment “someday.”

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

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