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TOA
President's
Update
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By John T. Gill, MD
President, Texas Orthopaedic Association
During the
2008 AAOS Annual Meeting in San Francisco, I will have the
honor of taking over as Chairman of the Board of
Councilors. The current chairman is Matt Shapiro of Eugene,
Oregon and following me will be Tom Barber of Oakland,
California. I will continue to serve on the AAOS Board of
Directors for my third and final year. Because you may
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or may not know what the Board of Councilors is, I
thought I would take this opportunity to shed some light.
The BOC is basically your house of representatives to the
Academy, representing all 50 states, Puerto Rico and Canada. Councilors
are elected by their respective state orthopaedic societies. Every
state has at least one councilor and some have proportionally more,
depending upon the number of orthopaedic surgeons in that state. Terms
are three years, with one renewal. In all, there are 102 councilors,
Texas has five.
The BOC
serves as an advisory body to the AAOS Board of Directors and a resource
to AAOS committees. In addition, the BOC manages AAOS' relations with
the state orthopaedic societies. This includes conducting a wide range
of programs to strengthen and support the state societies
organizationally.
The
Board of Councilors meets three times a year; at the Annual meeting, in
Washington DC in the spring, and again in the fall, which this year will
be in Dallas.
Major activities at these meetings include:
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making
recommendations regarding resolutions and proposed bylaws changes from
the AAOS fellowship;
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exploring AAOS
health policy, education, communication, research, membership and
governance issues and formulating specific recommendations to the AAOS
Board and other AAOS leadership bodies on these issues;
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visiting
Congressmen, Senators and other federal officials to promote the
interests of orthopaedic surgeons and their patients (National
Orthopaedic Leadership Conference); and
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developing AAOS and
state society leadership capabilities through skill building exercises
and other educational programs.
The
Board of Councilors is your link to the AAOS leadership and AAOS
decision-making. We need your input. Please feel free to contact me, or
your local Councilor with your comments and concerns, anytime.
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Educational Sessions on Workers
Compensation Medical and Hospital Fee Guidelines Offered in San
Antonio on Feb 7
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The
Texas Department of Insurance, Division of Workers' Compensation (TDI)
will present two educational sessions, Newly Revised 2008 Hospital Fee
Guidelines and Newly Revised 2008 Medical Fee Guidelines. These
educational sessions are sponsored by the University of Texas at San
Antonio (UTSA) Small Business Development Center on Thursday, February
7, 2008. The sessions will take place at the UTSA Downtown Campus,
Durango Building, Southwest Room, 501 W. Durango Blvd. The |
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cost is $50 per person for
each session. To register for the educational sessions, contact Laura
Gilliland, University of Texas at San Antonio Small Business
Development Center, by calling 210-458-2047 or emailing
Laura.Gilliland@utsa.edu.
The complete news release concerning the
educational sessions on workers' compensation medical and hospital fee
guidelines offered in San Antonio on Feb 7, can be located by clicking
here.
For more information on additional educational
sessions on workers' compensation medical and hospital fee guidelines,
please visit the TDI website by clicking
here.
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Industry-Wide Enforcement of the NPI Compliance Date
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The
compliance date for the NPI for all HIPAA covered entities
except small health plans was May 23, 2007. (Small health
plans have until May 23, 2008 to comply.) In guidance provided
on April 2, 2007, CMS announced that, through May 23, 2008, it
would not impose penalties on covered entities that deploy
contingency plans to facilitate the compliance of their
trading partners. On May 24, 2008, CMS will lift its
enforcement-leniency policy. Complaints will be investigated
as they are
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today, but
penalties will be a legitimate resolution if the entity does not
demonstrate compliance or corrective action. CMS will continue to
employ a complaint-driven approach to enforcement. For example, if a
complaint is received alleging a failure to comply with the NPI
requirements, CMS will contact the entity to secure evidence of
compliance and the contingency plan that had been in place. If
violations are identified, enforcement actions will take place.
This notice does not
prohibit covered entities from lifting contingency plans prior to May
24, 2008.
In sum, no later than
May 24, 2008, all covered entities are expected to be using the NPI in
a compliant manner, and all contingency plans should be lifted.
Important Information for Medicare Providers
Medicare’s Key Dates
There are two key dates remaining for 2008 in Medicare's NPI
implementation plan. There is also some confusion as to the
difference between the implementation steps for March 1st and May
23rd. The chart below indicates the implementation steps for each
date; as well a new column to help further clarify the difference
between these two dates.
|
Date |
Implementation
Steps |
Key Point |
|
March 1, 2008 |
Medicare FFS 837P
and CMS-1500 claims must include an NPI in the primary provider
fields on the claim (i.e., the billing, pay-to, and rendering
provider fields).
You may continue to submit NPI/legacy pairs in these fields or
submit only your NPI on the claim. You may not submit claims
containing only a legacy identifier in the primary provider
fields.
Failure to submit an NPI in the primary provider fields will
result in your claim being rejected or returned as unprocessable.
Until further notice, you may continue to include legacy
identifiers only for the secondary provider fields. |
Claims with
only legacy identifiers in the primary provider fields will
be rejected. |
|
May 23, 2008 |
In keeping with
the Contingency Guidance issued on April 2, 2007, CMS will lift
its NPI contingency plan, meaning that only the NPI will be
accepted and sent on all HIPAA electronic transactions (837I,
837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR
remittance advice. (Note that this date is one day earlier than
that mandated by the National Enforcement Policy)
This also includes all secondary provider fields on the 837P and
837I. The reporting of legacy identifiers will result in the
rejection of the transaction.
CMS will also stop sending legacy identifiers on COB crossover
claims at this time. |
If the claim
contains a legacy identifier in any field, it will be rejected. |
Only 4 Months Until May 23rd - Test NPI-only claims NOW
While Medicare is receiving well over 90% of claims containing an NPI
in primary provider fields, there is a very small percent of claims
submitted with NPI- only. Until you submit claims with an NPI-only,
you will not have a preview of what your experience will be on May
23rd. The time for correcting problems, should there be any, is
getting short. CMS urges that ALL Medicare providers test NOW so that
problems can be resolved prior to May 23rd. For example, if there is a
problem that requires a change in your Medicare enrollment
information, you will need to act immediately.
How to test - After
Medicare providers have submitted claims containing both NPIs and
legacy identifiers and those claims have been paid, Medicare urges
these providers to send a small batch of claims now with only the
NPI in the primary provider fields. If the results are positive,
begin increasing the number of claims in the batch.
(Reminder: For institutional
claims, the primary provider fields are the Billing and Pay-to
Provider fields. For professional claims, the primary provider fields
are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to
Provider is the same as the Billing Provider, the Pay-to Provider does
not need to be identified.)
Remember, if you test and your claims
are processed successfully, you can approach the May 23rd date with
confidence. If you do not, you may face unanticipated cash flow
problems.
Medicare
DMEPOS Suppliers: If Your Claims Are Rejecting!
Medicare DMEPOS
suppliers may be experiencing claims rejections if they did not obtain
their NPIs properly, if they are not properly enrolled in Medicare, or
both. For example, if a DMEPOS supplier who is a sole proprietorship
enrolled with the National Supplier Clearinghouse (NSC) as an
organization and furnished an Employer Identification Number (EIN)
instead of a Social Security Number (SSN), but obtained a National
Provider Identifier (NPI) as an Entity type 1 - Individual, the
Medicare NPI Crosswalk will be unable to link that DMEPOS supplier's
Medicare legacy identifier (the NSC number) to its NPI. This is
because the NSC number and the NPI identify different entity
types--one identifies an organization and the other an individual.
When a linkage between a Medicare legacy identifier and an NPI used in
a claim does not exist in the Medicare NPI Crosswalk, the claim will
reject. DMEPOS suppliers should contact the DME MAC if they do not
understand the error message they received.
If the rejection was due to the
inability of the Medicare NPI Crosswalk to link the NPI to the NSC
number, the DMEPOS supplier should check the NPPES record to ensure
the appropriate Entity type (1 = Individual; or 2 = Organization) is
reflected in that record. Individuals (including sole proprietorships)
obtain NPIs as Entity type 1. Organizations obtain NPIs as Entity type
2. If the NPPES record shows the appropriate Entity type, the DMEPOS
supplier should contact the NSC to ensure the enrollment record is
correct. If the NPPES record does not show the appropriate Entity
type, the DMEPOS supplier needs to take action to ensure the
appropriate Entity type is selected. If assistance is necessary, the
NPI Enumerator (1-800-465-3203) can explain to the DMEPOS supplier how
this is done.
Once the NPPES record is
correct, the DMEPOS supplier needs to ensure that it is properly
enrolled in Medicare. The NSC, once contacted, will ask appropriate
questions to determine if the DMEPOS supplier is, in fact, a sole
proprietorship, and if so, properly reflected as such in the
enrollment record. The NSC will assist the DMEPOS suppliers in
correcting their enrollment records.
DMEPOS suppliers who are sole
proprietorships should be aware of the following:
-
A DMEPOS supplier who is a sole
proprietorship obtains an Entity type 1 (Individual) NPI.
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When enrolling in Medicare (form
CMS-855S) with the NSC, a DMEPOS supplier who is a sole
proprietorship furnishes his/her SSN as the Taxpayer Identification
Number (TIN).
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The Legal Name of the sole
proprietorship business is the sole proprietor’s name.
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It is possible for the sole
proprietorship to have a “doing business as” (dba) name. The dba
name can be reported on the CMS-855S and in the NPI application (in
the “Other Name” field). A dba name, however, is not a Legal Name.
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It is possible that the sole
proprietorship requested and received an Employer Identification
Number (EIN) from the IRS if the sole proprietorship has employees.
This EIN will protect the sole proprietor’s SSN from appearing in
claims and on W-2s.
-
Medicare will treat the EIN as the TIN
for purposes of claims processing, but the SSN must still be
reported on the CMS-855S.
-
When Medicare reports tax information
to the IRS for that EIN, the IRS will link that EIN to the sole
proprietor’s SSN.
Additional Information on Reporting a
National Provider Identifier (NPI) for Ordering/Referring and
Attending/Operating/Other/Service facility for Medicare Claims
Click
here for a recently released MLN Matters Article on the topic of
reporting NPIs for order/referring and
attending/operating/other/service facility for Medicare claims.
CMS to Host National NPI Roundtable on 2/6/2008
CMS will host a national NPI Roundtable on Wednesday, February 6th
from 2:30 – 4PM ET. This call will focus on the status of the Medicare
implementation and a related question and answer session. Registration
details are available
here on the CMS website.
WEDI to Host NPI Audiocast
The Workgroup for Electronic Data Interchange (WEDI) will host an
audiocast to discuss NPI implementation from an industry-wide
standpoint. The audiocast will be held on February 21, 2008. Click
here for
registration details. Please note there is a charge to participate in
WEDI events.
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CMS Updates Reimbursement Schedules
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The U.S. Centers for
Medicare and Medicaid Services (CMS) has released updated Medicare
physician fee schedules for the first half of 2008. The new formula
reflects the 0.5 percent increase enacted by Congress in December to
replace a scheduled 10.1 percent reduction in reimbursement. The
formula will apply until July 1. Without Congressional action before
July 1, physician reimbursements will be reduced according to the
flawed sustainable growth rate (SGR) formula. Physicians have
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until February 15 to make
any changes to their participation status, with all changes being
retroactive to January 1, 2008.
For more information please click
here.
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