Newest MMP Report Identifies Coverage Risks
Help for the Weary
Hospitals are constantly struggling to follow everyone’s guidelines it seems – JCAHO, commercial payers, Medicaid, and Medicare, just to name a few. No wonder hospital staffs are weary, wary and stressed! Medical Management Plus (MMP) is proud to announce a new report that offers help for the weary.
In April, the Wednesday@One monthly Medicare coverage article discussed the importance of hospitals having a process in place to address Medicare coverage policies. Such a process should ensure compliance with the coverage requirements and prevent medical necessity denials as a result of failing to follow the coverage guidelines. One of the suggestions from the article is to evaluate coverage policies for services your facility offers that are “at risk.” Hospitals should consider the volume of the services they offer, the reimbursement amounts for these services, and the conditions of the policy. Another component in evaluating risk is recognizing the review targets of Medicare contractors and affiliates.
In order to assist our clients in determining services with potential risks associated with Medicare coverage policies, MMP is adding a new report to our HIQUP suite of reports. As we all know, Medicare manual instructions, Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) define the medical conditions, indications, and limitations for coverage of certain services. The new report identifies a facility’s financial risk should certain services be subject to a Medicare review. The select services have been identified by MMP as services at high risk because:
- They have significant reimbursement,
- The coverage determination requirements are quite detailed, and/or
- They are at increased risk of scrutiny by Medicare contractors or affiliates.
The new Medicare Coverage Policies Report will be launched in June and initially addresses six high risk services – AICDs and pacemakers, cardiac and pulmonary rehab, HBO, and sleep studies. Additional services will be added to the report over time for both national and local coverage policies specific to the client’s MAC region.
MMP recommends that providers verify their claims for these services meet all the appropriate criteria as specified in the coverage policy. A listing of the specific accounts is included in the HIQUP Account Listing Attachment and hyperlinks to the main coverage policy for each identified service are included in the report for easy access. Additional resources, including findings from reviews by MACs, Recovery Auditors, Supplemental Medicare Review Contractors, the OIG, and other Medicare reviewers if applicable, will be available through another hyperlink within the report that directs users to the Resources for Coverage Policies Guide on our website. This additional information allows providers to understand what issues have resulted in denials for other providers and what documentation specifics Medicare reviewers are looking for.
There is also a future benefit to knowing the coverage policies. As Medicare payments move from Fee-for-Service towards Value Based Purchasing, hospitals must find ways to provide the most effective care in the most efficient and cost-conscious manner. Appropriate utilization of services, that is performing only those services that are necessary for the patient’s condition and not performing unnecessary procedures, will be a major consideration in meeting this challenge. Facilities may find the Medicare coverage policies a useful tool in helping to determine the appropriate utilization of services.
Coverage updates for last month are listed below.
Article by Debbie Rubio
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.