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NHIA Acts To Lessen the Burden of Billing Medicare for Denial

(May 7, 2010)

 

NHIA has filed a ‘HIPAA complaint’ against the Centers for Medicare & Medicaid Services (CMS) for violating the agency’s own HIPAA administrative simplification regulations requiring that health plans must use standard medical code sets. NHIA has taken this action to press for improvement in Medicare’s burdensome requirements imposed upon home infusion providers when they submit ‘billings for denial’ to Medicare Part B.

Original Medicare’s coverage for home infusion is woefully inadequate for most Medicare beneficiaries, a situation which is NHIA's highest priority issue to correct.  Yet home infusion providers can serve some Medicare beneficiaries when they have secondary commercial insurance to cover their infusion therapies.  Before getting paid by many secondary insurers, infusion providers must first submit claims to Medicare to obtain denials of payment by Medicare.

Because original Medicare’s billing codes for home infusion are different from the industry-standard per diem coding used by private and some government insurers, it is extremely burdensome for providers to obtain timely payment from the secondary insurers. Medicare’s continued refusal to accept the industry-standard per diem codes (called HCPCS S-codes) for home infusion is contrary to the administrative simplification goal of HIPAA.

HIPAA is the Healthcare Insurance Portability and Accountability Act of 1996 which required providers and health plans to use standardized electronic claiming data formats and coding. NHIA filed its HIPAA complaint to the CMS Office of E-Health Standards & Services (OESS) which is responsible for enforcing HIPAA’s electronic claim regulations.

To help providers understand original Medicare's current infusion billing for denial requirements and how to package denied claims for secondary payment, NHIA makes available two educational reference tools: