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From the Reimbursement Team: CURES Act Retro Adjustments Coming May-Nov.

Posted on in Billing/Reimbursement, HME Government Issues, Legislation

By Ronda Buhrmester and Dan Fedor, VGM Reimbursement Specialists

You know the old slogan, “Do you want the good news first or the bad news?” Well, we are optimistic, so we will give you the good news first.

Good News – Mass Adjustments Starting in May Not July!

 They are starting two months earlier than expected, AND providers do not have to take any action as these will be processed as a MASS ADJUSTMENT.

Bad News – Mass Adjustments will Take Approximately 24 Weeks to Complete!

Here’s what we know as of today: The DME MACs are beginning to release more information from the CURES Act about the additional reimbursement coming to suppliers in the non-competitive bid areas for dates of service July 1 – Dec. 31, 2016. The initial expectation was that the mass adjustments would begin around July 3, but according to the recent release from the DME MACs, these adjustments have already begun and will continue over the next six months (Nov. 2017). Yes, six months.

Why is it taking six months to adjust these claims? The reason is there are a lot of claims (millions), and the DME MACs are the only ones that can do this and still process new claims. The processing system couldn’t handle it if they released millions of claims for reprocessing while still releasing new claims. We believe they conducted an analysis of how many claims can be released daily without impacting the processing of current claims and this is it.

Jurisdiction A and Jurisdiction D adjustment started May 12. Noridian has begun mass adjustments to all claims covered under the rule and has initiated adjustments for 20,000 claims each day for Jurisdiction A and 20,000 claims for Jurisdiction D for the next 24 weeks as directed by CMS.

Jurisdiction B and Jurisdiction C adjustment started May 10. CGS Jurisdiction C has begun adjusting approximately 40,000 claims each day for approximately 24 weeks. CGS Jurisdiction B has begun adjusting approximately 20,000 claims each day for approximately 24 weeks. 

According to the DME MACs, they are currently providing CMS a lot of feedback that may or may not change the current direction. They were informed that the adjustments will be done at random, meaning that there will not be a particular sequence that will be followed (not by NPI, not date of service – at this point). Our opinion is that they suspect that once the adjustments start processing, there will be a pattern and a processing schema. Unfortunately, this information hasn’t been shared with the DME MACs. The only thing being shared by CMS is that the processing will be random. 

How will we know a CURES Act-adjusted claim? You won’t. There also will not be a particular identifier (e.g., remark code, unique CCN) that will be associated with these adjustments that would allow suppliers to separate CURES Act adjustments from other adjustments. Suppliers will have to identify the codes and dates of service for the claims to be adjusted internally and reconcile once they are adjusted for additional payment. 

Do suppliers have to do anything? Not for the mass adjustment, but you should request a written reopening for the KE claims. According to the DME MACs, they will accept the KE modifier for those claims affected but not until the mass adjustments have been completely processed. Once the claim has been adjusted, suppliers will need to request a written reopening requesting to add the KE modifier to the affected codes to receive the additional five percent.  

Suppliers will not be permitted to request escalated processing of these claims.

As a side, the DME MACs know that this is a big deal for the supplier community and will be working to share as much as they can. 

What We Also Know

  • The claims should automatically crossover to the secondary payer. As we all know, in situations like these processes do not always run smoothly. This may require suppliers to manually submit to the secondary payer.
  • We suggest you prepare your staff for incoming calls from beneficiaries who will get a notice of summary and will have questions.
  • It’s important to be working with your billing software company to understand the best method for posting these payments because the invoices are already closed.

Click on the following links for the announcement about the mass adjustments:

Stay tuned for additional information, and please let us know if you experience issues.

Contact Information:

Ronda Buhrmester: Ronda.Buhrmester@vgm.com; phone: 888-665-6518
Dan Fedor: Dan.Fedor@vgm.com; phone: 844-794-8459