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MEDICARE REQUIREMENTS FOR 2010
RAC (Recovery Audit Contractor)
Medicare Documentation Requirements
Frequently Asked Questions Regarding RAC
Medicare Quantity Allowables for Diabetes, Urology, Ostomy and Wound Care
PECOS (Provider Enrollment, Chain and Ownership)
Healthcare Provider: PECOS Enrollment
CMS letter to physicians regarding PECOS
To register with PECOS _______________________________ RAC (Recovery Audit Contractor)
Medicare Documentation Requirements
As part of the The Tax Relief and Health Care Act of 2006, the Centers for Medicare & Medicaid Services (CMS) has introduced an increased level of scrutiny to their audit process. CMS has engaged four third party contractors, RACs (Recovery Audit Contractors), to audit claims. These audits will be more frequent and more intense than prior audits. Medicare requires the following documentation to validate the dispensing of home medical supplies to beneficiaries:
1. A dispensing order
2. A signed and dated detailed written prescription
3. Medical records that substantiate the detailed written prescription In the event that this documentation is not available upon invoice submission or a Medicare audit, Medicare will deny the claim or request a refund from the supplier.
The RACs are paid 100% on contingency. Frequently Asked Questions Regarding RAC:
1. What does this mean for healthcare providers?
When presented with a Medicare audit Byram Healthcare will require you to provide medical records (progress notes, chart notes, lab reports, etc) that substantiate the medical supplies that were prescribed and approved via the detailed written prescription. If you are prescribing a quantity in excess of Medicare’s quantity allowables, Byram will request the medical records that substantiate the overage in advance of shipping re-orders for beneficiaries. For the on-going prescription of overages, Byram will require updated medical records every 6 months. 2. What are Medicare quantity allowable guidelines?
Medicare has set the following guidelines for dispensing Diabetes, Urology, Ostomy and Wound Care supplies - Medicare Quantity Allowable Guidelines. 3. What is a “medical record that substantiates the detailed written prescription”?
Medical records can include, but are not limited to, chart notes, lab reports or progress notes which indicate the clinical need for the prescribed treatment. Appropriate clinical or medical data will indicate usage requirements in excess of Medicare quantity allowables. CMS guidance on medical records for glucose testing supplies 4. What happens if this material is not available?
Upon audit, Medicare will deny the claim for the medical supplies and request a refund for previously paid claims. 5. What does this mean for Medicare beneficiaries?
If medical records are not available to substantiate the items and quantity being prescribed this can mean that the patient may be unable to get supplies or may be required to pay out of pocket for their supplies. 6. This will be an additional burden on my administrative staff to handle this request. Can I refuse to provide the documentation?
As a Medicare provider, you must provide the appropriate medical documentation as required by CMS. 7. I have additional questions regarding this process. Who may I contact?
Please use the following email link to submit your question:
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. You will receive a response within 24 hours, Monday – Friday, via telephone or email. 8. Are there other Medicare regulations that will now be more deeply focused on during the audit process?
Signature legibility on prescriptions and medical records is another area of concentration. The Medicare Program Integrity Manual indicates that a “legible identifier” in the form of a handwritten or electronic signature is required. For more information visit: http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf Click here for additional information regarding RAC. _______________________________ PECOS (Provider Enrollment, Chain and Ownership) MEDICARE HEALTHCARE PROVIDERS MUST ENROLL IN NEW PECOS SYSTEM
CMS has established an internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners, and provider and supplier organizations. PECOS will allow physicians, non-physician practitioners and provider and supplier organizations to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, or check on status of a Medicare enrollment application via the Internet. Medicare healthcare providers are required to be enrolled in this system by July 6, 2010 to insure medical supplies are covered for their patients. Click here to view CMS letter to physicians regarding PECOS.
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