CMS - Centers for Medicare and Medicaid Services

December 23, 2011

Attention Health Professionals: 2012 Annual Participation Enrollment Program Extension

CMS is anticipating Congressional action to avert the negative update for the 2012 Medicare Physician Fee Schedule.

Therefore, CMS is extending the 2012 Annual Participation Enrollment Period through Tue Feb 14, 2012.  The enrollment period now runs Mon Nov 14, 2011 through Tue Feb 14, 2012. 

The effective date for any participation status change during the extension, however, remains Sun Jan 1, 2012, and will be in force for the entire year.

Contractors will accept and process any participation elections or withdrawals made during the extended enrollment period that are post-marked on or before Tue Feb 14, 2012.

CMS - Centers for Medicare and Medicaid Services

December 19, 2011

Attention Health Professionals: Information Regarding the Holding of 2012 Date-of-Service Claims for Services Paid Under the 2012 Medicare Physician Fee Schedule

The negative update under current law for the 2012 Medicare Physician Fee Schedule is scheduled to take effect on Sun Jan 1, 2012, eight business days from today.  Consequently, as on numerous occasions in the past, CMS will instruct its Medicare claims administration contractors to hold claims containing 2012 services paid under the Medicare Physician Fee Schedule for the first 10 business days of January 2012 (i.e., Sun Jan 1 through Tue Jan 17).  The hold should have minimal impact on provider cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. 

Medicare Physician Fee Schedule claims for services rendered on or before Sat Dec 31 are unaffected by the 2012 claims hold and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk.  We continue to urge Congress to take action to ensure these cuts do not take effect.

CMS will notify you on or before Wed Jan 11, 2012, with more information about the status of Congressional action to avert the negative update and next steps regarding the claims hold.

AMA

Update on January 1, 2012 HIPAA 5010
Compliance Deadline

January 1, 2012 marks the compliance deadline for use of the new version of the standard electronic Health Insurance Portability and Accountability (HIPAA) transactions.  Version 4010 has been in use since 2003 and the Centers for Medicare and Medicaid Services (CMS) is requiring all HIPAA "covered entities," which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e. claims or remittance advice), to begin using Version 5010 starting on January 1, 2012. 

The AMA has been extremely proactive in educating physicians and continues to make a wealth of easy to understand resources available for free on our website at www.ama-assn.org/go/5010.  Despite significant efforts by many in the health care industry, including physicians, there remains a considerable amount of work that needs to be done before everyone will be able to use the new standards.  For example, many practices have not had their practice management system (PMS) software upgraded by their vendor and have not been able to conduct testing with key trading partners. If your PMS vendor has not yet updated your system to accommodate the use of version 5010 you are strongly encouraged to contact them to obtain the necessary software upgrades.

CMS Announces Enforcement Flexibility

CMS is the federal agency charged with oversight of HIPAA standards.  AMA and others advocated to CMS that overall lack of industry readiness should not compromise physician cash flow following the January 1, 2012 compliance date. For this reason, CMS has indicated they will not levy any enforcement actions for the first three months of 2012 while HIPAA covered entities continue to work towards compliance.  What this means is that the HIPAA 5010 compliance date remains January 1, 2012 and all physicians and other HIPAA covered entities should continue to make every effort to comply with the use of the new standards, but that CMS will not take any enforcement action during this period.

Medicare’s Plans

Medicare, as the largest insurer that is required to comply with HIPAA requirements, has indicated that they are continuing to work with those who submit claims directly to them  (Submitters).  Submitters” include clearinghouses, third party billers, and physicians who submit claims directly (without the use of a third party or clearinghouse) to Medicare.  Every submitter is required to test with Medicare before claims can be processed using the 5010 format.  Medicare remains focused on ensuring all Submitters have tested successfully and that claims processing is not interrupted.  “What this means for physicians:

            Direct Submitters

If you are a physician who sends claims directly to Medicare (“Submitters”) without the use of a billing service or clearinghouse:

• If you HAVE NOT tested by December 31, 2011: You are required to submit a "transition plan" to your Medicare contractor that details your plans for moving to 5010 and when you think you will be able to test with Medicare.  You will have 30 days to do this once you have been contacted by your Medicare contractor.
• No prescribed format for transition plan:  It can be sent via letter, email, or fax and can be a brief explanation of your transition plans.   
• Keep evidence plan was submitted: Submitters are strongly encouraged to retain evidence that a plan was sent (i.e. return receipt email, fax transmission confirmation, copy of an email).  
• All submitters must test: Unless submitters have tested with their Medicare contractor, even if you submit compliant 5010 transactions, your claims will be rejected. 

• If you HAVE tested successfully by December 31, 2011: You will be contacted by Medicare and told you have 30 days to move over to use of the 5010 standards.  Submitters that have not yet tested with Medicare prior to the compliance date will be contacted and asked to submit the transition plan described above. 

Physicians who use a clearinghouse or billing service to submit their claims

Physicians who rely on a billing service or clearinghouse to submit their claims to Medicare are NOT required to file a transition plan to Medicare.  The entity they use to submit their claims is the Submitter and is the one required to submit a transition plan.  These physicians should contact their billing services or clearinghouses to determine their ability to generate the physician’s claims and other transactions using the Version 5010 format.

For More information

For more information on 5010 please visit www.cms.gov/Version5010andDO and www.ama-assn.org/go/5010.