Medicare PPS – are we having fun yet?

Categories: Billing, FQHC, PMG Insights Blog

March 30, 2015

The Transition to PPS Payment Methodology

The transition to the PPS payment methodology for Medicare has not been as seamless as some would’ve thought. When the details were first published, there were many unanswered questions and some software vendors had not even prepared a response to how these changes would be applied in the systems that they support. Fast forward six months, we are closer to streamlining the process but it is still a work in progress.

Since October 1, the way that we think about Medicare billing in an FQHC setting has changed in many ways. The definition of a new patient has been altered for purposes of PPS. Visits that once met the definition of an encounter, no longer do. In addition, I am finding that managing Medicare receivables has become slightly more challenging as questions continue to arise. We do have more information now than when the first claim was sent out on October 1 and are continually reviewing processes to develop strategies for questions that continue to arise on an almost daily basis.

We’ve discovered that some of the Medicare Advantage plans wish to be billed in the same manner as traditional Medicare. This was true for some with the all-inclusive model and we find this to be the case with PPS as well. Secondary payers present challenge as well. The G codes were developed by Medicare for the purpose of reporting a qualifying FQHC visit. These codes are not recognized by most secondary payers yet these are the codes to which Medicare has applied the payment. CMS is assisting providers to get these codes recognized by secondary payers.

Medicare Secondary Payer

While folks have had struggles with billing MSP claims in the past in the all-inclusive model, this is further complicated with the transition to PPS. Medicare is expecting the G code on the MSP claim and in many cases; the question is how to get them on there. Some PM systems can be configured to automatically add the details but it doesn’t resolve the issue with missing COB information necessary to balance the claim. What about those systems that cannot automatically add the information? There have been suggestions that the G codes be submitted on any claim where Medicare might be billed, whether primary or secondary. What does this do to the existing workflow? How do you identify when the codes should or shouldn’t be added? How does this impact reporting?

There have been significant changes in existing workflow as it relates to Medicare receivables. Additional intervention is required on multiple levels. Decisions must be made as to how visits that no longer meet the ‘qualifying visit’ definition are handled. What action is required to manage the AR for those visits? The G codes are added, with an associated fee, to the Medicare claim. Should those claims deny for eligibility, those codes/fees must be removed prior to billing the claim to the patient as they are not responsible for those charges. Medicare claims require more ‘touches’ with PPS than ever before. Fortunately, with Medicare, there are some guarantees regardless of the payment methodology in use – denials in three days and payment in ten. One way or another, an answer will be provided.