June 06, 2017
There are multiple concerns about the changes implemented by Wisconsin Physician Services, Inc. (WPS) on Feb. 16. Since then, other Medicare Contractors have incorporated these changes in their Local Coverage Determinations (LCD).
The Centers for Medicare and Medicaid Services (CMS) began 2017 with a goal of mitigating the risk of increased Office of Inspector General (OIG) audit findings for sleep centers. Past OIG audits have revealed several overpayments and a lack of controls to ensure full compliance with Medicare requirements. The OIG developed recommendations based on their findings—one of which increases controls for sleep centers. CMS has provided each Medicare Administrative Contractor (MAC) authority to develop LCDs for items and services within their jurisdiction.
WPS (J5: Iowa, Kansas, Missouri and Nebraska) was the first MAC to revise their LCD (L36839) accreditation requirements. Originally, the policy stated that The Joint Commission (TJC) accreditation was sufficient for billing purposes. The revisions now required hospital-based sleep centers to obtain TJC sleep specific credentials for ambulatory care sleep centers or receive credentials through the American Academy of Sleep Medicine (AASM) or the Accreditation Commission for Health Care (ACHC). The addition of “ambulatory care sleep centers” affected hospitals’ ability to rely on their accreditation of TJC to meet the requirements.
It did not take long for other MACs to review, revise and incorporate their policies to include these accreditation requirements. The Celerian Group (CGS-J15) completed their revisions for L36902 with an effective date of March 6, 2017. Palmetto was the next MAC to make these revisions for L36593 with an effective date of April 27, 2017, and Noridian Healthcare Solutions (JE and JF) has an effective date of June 5, 2017, for their L36861. First Coast did not have to make a revision to L33405 as these accreditations were already part of the requirements.
The new requirements will affect all hospitals, including rural hospitals, if sleep studies will be performed at their site. The MACs will deny all claims that are billed from a hospital that does not have the required accreditations after the implementation of their policies. There have been several attempts of reconsiderations and/or delays of the effective date that have not been successful. This change is a clarification of the previous policy, and at this time there will be no change to these effective dates.
The Accreditation Organizations are aware of the challenges and have worked to help clarify and assist with making the process quick and easy.
Sleep centers: Zero in on these changes and use this knowledge as power. Don’t wait to receive denials. These changes have caused several concerns over the past few months. Take time to review your credentials and confirm that you are currently meeting your MAC’s policy requirements.
If you have questions about how to develop a proactive denials management program, please contact your Eide Bailly representative, Amber Broderson or Rhonda Quast using the contact information below.