Delays in Medicare Reimbursement

DATE: March 20, 2012 TO: AACE Members RE: Delays in Medicare Reimbursement AACE’s Socioeconomics & Member Advocacy Department has received several inquiries from the membership regarding delays they are experiencing in Medicare reimbursement. Three issues have been identified that may be impacting your office practice: 1) Electronic prescribing (eRx) Effective January 1, 2012, a one-percent penalty was assessed to eligible professionals that did not participate in CMS’ 2011 Electronic Prescribing Incentive Program. CMS’ required eligible professionals who did not meet the criteria to submit prescriptions electronically needed to request a hardship exemption. The request had to be submitted during the first, six-months of 2011 to avoid the 2012 penalty for eRx. One of the issues that has been identified regarding eRx is eligible professionals who submitted their hardship exemption requests may have been assessed the one-percent reduction in their Medicare payment. CMS indicated that it has not reviewed and approved all of the hardship exemption requests due to limited resources. If a physician did not receive approval from CMS, a reduction in Medicare payment may have occurred. Once CMS reviews the requests and determines that the eligible professional met the hardship exemption criteria, those claims will be reprocessed accordingly. The other issue related to the hardship exemption requests is that if the eligible professional’s information was incorrect or incomplete, the one-percent penalty would be assessed. During CMS’ National Provider Call, the CMS representatives emphasized that these requests must be correct and complete. CMS is not allowing eligible professionals to re-submit their request with updated information at this time. 2) Physician Quality Reporting System (PQRS) CMS has recently identified an error related to the submission of Measure #235 “Hypertension: Plan of Care” for the 2012 Physician Quality Reporting System. Hypertension: Plan of Care is a claims/registry measure with G-codes that are inactive due to an error found on the HCPCS tape. This has resulted in claims containing the G-codes associated with the measure being rejected by the carrier/Medicare Administrative Contractor (MAC) or denied. The HCPCs codes (G8675, G8676, G8677, G8678, G8679, G8680, 4050F) will be reactivated with the next update of the HCPCS tape in April 2012. For 2012 claims-based reporting, PQRS requires at least 3 measures to be reported at a 50% reporting rate. In the interim, eligible professionals who had intended to report this measure via claims for the 2012 PQRS reporting period may want to consider taking one of the following steps:

  • Report the measure on more than 50% of eligible visits from April through December 2012 to increase the likelihood for successful reporting of the measure; or
  • Consider reporting additional measures to substitute for Measure #235 "Hypertension: Plan of Care."
3) HIPAA 5010 The version 5010 deadline was January 1, 2012; however, because of the 180-day enforcement discretion period for all HIPAA covered entities upgrading to version 5010 CMS will not initiate enforcement action until June 30, 2012. CMS made this decision based on industry feedback that many organizations and their trading partners were not yet ready to finalize system upgrades to be compliant. CMS encourages physicians to continue internal testing as well as external testing of version 5010 transactions with trading partners to ensure compliance for version 5010. Although enforcement action will not be taken prior to June 30, 2012, it is important that you continue to move forward to meet version 5010 requirements as soon as possible. In addition to testing, if you have not yet created a plan for version 5010, you should do so in order to meet these compliance deadlines. CMS provided direction to HIPAA covered entities to submit a transition plan to their local MAC outlining how they will complete their transition to HIPAA 5010 by March 31, 2012. CMS had initially indicated that they would instruct the MACs to reject the 4010 claims if a transition plan was not received. At this time, the MACs have not been given guidance to reject 4010 claims. AACE staff spoke with Dr. William Rogers, Director of Physician Regulatory Issues Team at CMS regarding HIPAA 5010 implementation concerns. Dr. Rogers stated that during the first two weeks of January, the MACs were experiencing issues with the claims processing system, but those system problems have been resolved. We strongly encourage you to verify with your clearinghouse/billing companies that they have converted to version 5010 and have successfully tested the upgrades with your federal and commercial payers. If your clearinghouse/billing company has successfully tested with your local carrier/MAC, they will be listed on the carrier’s/MAC’s web site under the Electronic Data Interchange (EDI) section, Approved Vendor List. Remember: Upgrading to version 5010 is a critical first step for the nationwide transition to ICD-10 that will take place on October 1, 2013, if CMS does not delay implementation. It is important that you finish this process, so that you can continue to prepare your organization for the ICD-10 transition. In addition, the MACs have received inquiries regarding edit 496; this edit may occur in different instances. The problem may be the result of a provider not being properly linked to a clearinghouse/vendor submitter in Medicare’s system or it may also be the result of billing errors. The following tips will assist you and your practice in determining the reason for receiving edit 496 and help you with resolving these errors:
  • Ask your clearinghouse/billing company to make sure that the linkage between the vendor and Medicare is valid. If the linkage is bad, you will receive an error message ‘Submitter not approved for electronic claim submissions on behalf of this entity.
  • Ensure that your staff is submitting the correct NPI (rendering versus billing provider NPI). For example, billing Part B services for a provider associated with a group under his/her individual NPI instead of the group’s NPI would cause a billing error.
Your clearinghouse/billing company should evaluate all edits to determine if the issue is a billing error, prior to contacting the MAC for a linkage problem resolution. Should you have any questions, please contact the Socioeconomics & Member Advocacy Department at 1-800-393-2223. Please click here to read the memo as a PDF


AACE Clinical Practice Guidelines are systematically developed, evidence-based documents that assist practitioners about appropriate health care decisions

AACE Position Statements

AACE's Position Statements meet rigorous criteria before being published and utilized and serve as one of the worlds' most trusted sources


AACE continually strives to bring to the world definitive protocols, guidelines and discoveries which further and enhance the greater medical health of the general public.

Find an Endocrinologist

Find an Endocrinologist in your area by entering a ZIP code, or your city and state using our search feature.