CMS Contracting Changes
Medicare shortly will implement some contracting changes which have implications for the hospital and other providers.
CMS has begun to eliminate its relationship with its carriers, NHIC for BWH, and fiscal intermediaries, NGS for the BWH. Instead, CMS has begun to award contracts to entities that will integrate the administration of Medicare Parts A and B claims. These new entities are called Medicare Administrative Contractors, or MACs, which will serve as the primary point-of-contact for enrollment in Medicare, training on Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for-service claims within their respective jurisdictions. There will be a single MAC that covers all providers for Massachusetts, Maine, Vermont, Maine and Rhode Island. The contract for this jurisdiction has not yet been awarded. It is unclear whether NHIC or NGS, or both, will be able to retain their current Medicare work, and BWH and its professional staff may be required to work with a new Medicare contractor.
Another substantial contracting change by CMS relates to how Medicare reviews hospital inpatient claims. In the past, Medicare used Quality Improvement Organizations, or QIOs, to review the appropriateness of such claims. However, CMS has recently determined that QIOs will focus their efforts on quality improvement, and the fiscal intermediary and the MAC, when that entity is determined, will be responsible for reviewing and determining the appropriateness of inpatient hospital claims.
Any questions on these changes in the Medicare program can be directed to the Billing Compliance Officer at 617-582-0092.