Billing Regulations: ACO/NCCI/LCD/NCD/ (Pg. 73-76)

Accountable Care Organizations (ACO)

• ACOs coordinate patient care, share information securely, and may use EHRs for better communication.
• Medicare patients participating in an ACO receive written notice or find information in a poster.
• Medicare beneficiaries can be assigned to an ACO, but not Medicare Advantage plans, HMOs, or PPOs.

National Correct Coding Initiative (NCCI)

• Developed by CMS for Medicare Part B and Medicaid claims.
• An automated system preventing duplicate billing for similar procedures on the same day.

Local Coverage Determination (LCD)

• Decision made by a Medicare Administrative Contractor (MAC) regarding whether a service is covered in their region.

National Coverage Determination (NCD)

• Nationwide decision on whether Medicare will pay for a specific item or service.
• If no NCD exists, coverage depends on local LCDs.

Incident-to Billing

• Allows billing for outpatient services provided by non-physician practitioners (NPPs) in certain settings.
• Examples of NPPs include nurse practitioners (NPs), physician assistants (PAs), and other non-physician providers.

Global Surgical Packages

• Medicare established a national definition to ensure consistent payment for surgical services.
• Designed to prevent Medicare payments for services that are bundled with the procedure.

Unbundling

• Improper coding practice where bundled procedures are billed separately for higher reimbursement.
• EHR software can facilitate unbundling.

CMS-1500

• Used for reimbursement of professional services by physicians and suppliers.
• Uniform format ensures consistency in claims across providers and insurers.
• Electronic version is called X12 837 Health Care Claim: Professional 837P
• Contains patient demographics, insurance policy information, and medical coding.

Claim Submission

• Photocopy insurance card and check expiration date and eligibility.
• Determine if prior authorization is required.
• Use CMS-1500 form for submitting claims.
• Claims must be signed by the physician and sent to a fiscal intermediary.
• Claims submitted after the time limit may be reduced or rejected.

UB-04

• Used for reimbursement of medical services provided by institutional healthcare providers.
• Examples include hospitals, rehabilitation centers, nursing homes, and home health settings.
• Electronic version is called 837I.
• Consistent format with CMS-1500 for easier processing.

Payer Payment Policies

• Certified staff responsible for collecting copays when patients register.
• Verification of patient insurance information and eligibility is crucial.
• Patients unable to provide payment require respectful handling.
• Patient aging report used for overdue accounts.
• Adjustments made to account balances to reflect contract amounts, credits, refunds, discounts, bad debt, and corrections.
• Allowed charge is the amount the payer will pay for a procedure.
• Reimbursement schedules vary depending on insurance company.

Methods for Determining Provider Payment Rates

• Charge-based fees based on providers with similar services.
• Resource-based methods consider complexity, overhead, and risk.
• Usual, Customary, and Reasonable (UCR):
  • Usual: provider's typical fee.
  • Customary: fees charged by similar providers in the area.
  • Reasonable: fee justifiable based on specific circumstances.
• Relative Value Studies (RVS): list with codes and corresponding values for procedures.

Test your knowledge on the various Medicare regulations including Accountable Care Organizations, coding initiatives, and coverage determinations. This quiz covers essential billing practices and the role of non-physician practitioners in Medicare services.