|
|
HIPAA/LAW:
September 2003
"Understanding the Final Rule for
Electronic Submission on Medicare Claims"
by Steve Fox & Rachel Wilson, Esqs., Pepper
Hamilton LLP
The Department of Health and Human Services ("HHS") recently
published the final rule for the Electronic Submission of Medicare
Claims (the "Rule") mandated under the Administrative
Simplification Compliance Act ("ASCA"). With few exceptions,
ASCA requires that all claims sent to the Medicare Program on or
after October 16, 2003 (the "Compliance Date") are submitted
electronically. The Rule is only applicable to providers, practitioners,
and suppliers who submit claims under Part A or Part B of Medicare.
It does not apply to claims submitted by providers to Medicare +
Choice organizations.
The Medicare Program is a covered entity subject to HIPAA regulations,
as it falls within the definition of a "health plan" under
HIPAA. Although the Transactions Standards promulgated pursuant
to HIPAA (the "Transactions Standards") are applicable
to electronic healthcare claims transmitted between covered entities,
they do not require covered entities to submit claims electronically.
In other words, as it relates to the submission of claims, the Transactions
Standards are only applicable to covered entities when and if they
choose to submit electronic claims. HHS estimates that approximately
139 million paper claims are submitted to the Medicare Program each
year. Congress enacted ASCA to improve the administration of the
Medicare Program by taking advantage of the efficiencies to be gained
through electronic claim submission. The move from paper to electronic
submissions is expected to result in significant savings for Medicare
physicians, practitioners, suppliers, and other healthcare providers,
as well as for the Medicare Program itself.
Electronic claims submission is only required for initial Medicare
claims, including initial claims with paper attachments, submitted
for processing by the medical fiscal intermediary or carrier that
serves the physician, practitioner, facility, supplier or other
healthcare provider. The Rule does not require any other transactions
(for example: changes, adjustments, or appeals to the initial claim)
to be submitted electronically.
Claims submitted via direct data entry mechanisms are considered
to be electronic claims for purposes of the Rule. In addition, claims
transmitted to a Medicare contractor using the free or low cost
claims software issued by Medicare fee-for-service plans are also
electronic claims for purposes of the Rule.
The only exceptions to the electronic claims submission requirement
under the Rule are as follows:
- There is no method available for the submission of an electronic
claim.
Three situations fall into this category: (i) roster billing of
vaccinations covered by the Medicare Program; (ii) claims for
payment under Medicare demonstration projects; and (iii) claims
where more than one plan is responsible for payment prior to Medicare;
- The entity submitting the claim is a small provider of services
or small supplier.
A small provider of services is a hospital, critical access hospital,
skilled nursing facility, comprehensive outpatient rehabilitation
facility, home health agency or hospice program with fewer than
25 full time equivalent employees (FTEs). A small supplier is
a physician, practitioner, facility, or supplier with fewer than
10 FTEs.
- The Secretary of HHS finds that waiver of the electronic submission
requirement is appropriate due to unusual circumstances.
Unusual circumstances will be deemed to exist in any one of the
following situations: (i) submission of dental claims, (ii) a
service interruption in the mode of submitting the electronic
claims that is outside of the control of the entity submitting
the claim, but only for the period of the interruption and subject
to the specific requirements set forth under the Rule, or (iii)
upon demonstration to the satisfaction of the Secretary of HHS,
that other extraordinary circumstances exist which preclude the
submission of electronic claims.
Under ASCA, no payment may be made under Part A or B of the Medicare
Program for claims submitted in non-electronic form. Absent a permitted
exception to the Rule, paper claims submitted to Medicare will not
be paid. Entities that fail to comply with the Rule may be subject
to claim denial, overpayment recovery and applicable interest on
overpayments.
HHS has made it quite clear that it does not intend to broaden
the extremely limited exceptions discussed above. For that reason,
if your organization expects to continue to receive Medicare payments
after October 16, 2003 (and if you hope to remain in your present
job), one hopes that you are well on the way to achieving compliance.
Read past HIPAA Legal Q/A articles.
Steve Fox, Esq., is a partner at the Washington, DC office of Pepper
Hamilton LLP, www.pepperlaw.com  .
This article was co-authored by Rachel H. Wilson, Esq., an associate
of Pepper Hamilton LLP. They may be reached at foxsj@pepperlaw.com. Disclaimer: This information is general in nature and should
not be relied upon as legal advice.
|
 |
 |
