Exact Match: How to Mitigate Medicare Claim Denials

Better start making your list and checking it twice.

Exact Match: How to Mitigate Medicare Claim Denials

Better start making your list and checking it twice.

No, we’re not suggesting you become Santa Claus. We’re referring to checking your Medicare Provider Enrollment, Chain, and Ownership System (PECOS) enrollment file to be sure your off-campus provider-based service location information is correct.

Soon hospitals with multiple service locations will be required to accurately enter the service facility address of their off-campus, provider-based departments when filing Medicare claims. Medicare Administrative Contractors (MACs) will implement an edit to the claims processing process that validates that off-campus hospital outpatient departments (HOPDs) where services are provided are Medicare-enrolled locations.

What could this mean for hospitals with HOPDs?

Denied claimsMedicare will reject claims when there is not an exact match between the information submitted on the hospital’s CMS Form 855A (and appearing in PECOS) and the off-campus HOPD service facility location reported on the hospital’s Medicare Outpatient Prospective Payment System (OPPS) claims. Even slight discrepancies in the addresses—“Rd” or “Ste” instead of “Road” or “Suite”—will cause claims to be rejected. 

Lost revenue. Hospitals could lose millions of dollars (up to $16 million for a large IDN with 121 hospitals, assuming 10% data discrepancy) or, at the very least, wait months to receive money from CMS. This may result in temporary cash flow problems. 

Costly claim resubmissionsIf the addresses don’t match exactly, hospitals will receive a return-to-provider notice. Billing staff will have to work with their MAC to revise and resubmit the claims. This process is expensive$118 average cost to reprocess a single claim1—and time-consuming. In the worst-case scenario, billing departments may miss the window to file claims. Under the Affordable Care Act, claims must be filed within one year from the date of service to be paid.  

How Can You Prevent Denied Claims? 

Check your list of off-campus HOPD locations. Make sure every off-campus HOPD location where your hospital provides outpatient services is listed as a practice location on your hospital’s CMS-855A enrollment form and included in your PECOS enrollment fileIf any locations aren’t listed, submit Form 855A to add the missing location(s).  

Identify discrepancies between the service location addresses in PECOS and your claims processing database. To do this, you’ll need to identify how service location addresses are entered in both systems and generate an exception report. query function in PECOS enables hospitals to confirm the exact address of an off-campus HOPD as listed in PECOS and match it to the location where the services are being provided as shown on Medicare claims.2 

Correct all discrepanciesMatch the addresses listed in PECOS with the service facility locations in your Medicare claimsTo do this, you can update the address in your claims-processing system or in PECOS. It can take 30 to 45 days to have MACs approve changes to a provider’s enrollment information.3  Therefore, for minor discrepancies (e.g., “Street” versus “St.”), it’s faster and easier to correct the service facility addresses in your claims-processing systems. If you need to add a new address or correct an existing practice location address, you will need to submit a new 855A enrollment application in PECOS. 

Train your billing staff to use the correct address-listing protocol.  

TractManager’s Provider Management experts can quickly identify your mismatched service addresses, submit all updates to CMS and PECOS, and ensure that you are not losing revenue moving forward. TractManager’s Provider Enrollment experts handle data entry and payer application submissions for Medicare, Medicaid, and commercial payers, making sure you start with accurate provider enrollment data.  

Sources: 

1 https://www.beckershospitalreview.com/finance/denial-rework-costs-providers-roughly-118-per-claim-4-takeaways.html 


https://www.bricker.com/people/shannon-debra/insights-resources/publications/hospitals-with-off-campus-provider-based-departments-check-your-pecos-enrollment-file 


3 https://www.modernhealthcare.com/operations/hospitals-have-month-fix-medicare-addresses-or-go-unpaid 

Author:

Allyson Schiff

Senior Director, Strategy & Growth, Provider Management

Allyson Schiff joined Newport Credentialing Solutions in 2009 and joined TractManager when Newport was acquired in 2018.

 

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