Tuesday, November 15, 2011

Denial reason - Medicare Presumptive Payment

Medicare Presumptive Payment Adjustments and Denials

Medicare presumptive payments are based upon the Social Security issuing a presumptive SSI that someone will actually start benefits before they have officially qualified. There are many severe conditions that will help a person to qualify for presumptive Medicare allow them to start paying into this category to get benefits to kick in. The standard method could take six months for all of the paperwork to be completed and the claim to be reviewed. This way, a person can begin Medicare benefits and healthcare immediately.

When a patient is under presumptive Medicare, they will visit the doctor as they would with any other type of insurance. The doctor's billing company then needs to use the proper code for Presumptive payment. If the Presumptive payment code is used for anything other than for this reason, there may be a denial, often as an A7 denial code: Presumptive payment adjustment.

The reason that many medical providers are getting the A7 denial code, however, is because they are using it to force balance the transactions. FIs, or Fiscal Intermediaries, are reporting the add-on payment in the claim/service adjustment segment as an additional payment that has already been included in the allowed amount. This is what's causing the out-of balance on the books, which is why many are using A7 to offset the difference.

The Medicare Presumptive payment adjustment doesn't typically affect the patients in a negative way. In fact, it will help most of them when used properly because they will get the care that they need in a timely manner as opposed to waiting for paperwork to process. They will be able to pay only what is required (if anything) so that they can get treatment.

Fiscal Intermediary Standard System (FISS) shall make programming changes to report a claim or line(s) level out of balance condition on the standard paper remittance advice to ensure that the SPR will balance at the claim level. The standard paper remittance advice report format will be modified to reflect a new field
‘Presumptive Payment Adjustment’.

The presumptive payment adjustment, ‘PRE PAY ADJ’, field will be added below the interest field in the Part A and Part B claim detail section. A new field “ADJUSTMENT TO BALANCE” will be added below the balance forward withhold field in the PROVIDER PAYMENT RECAP section in the Summary Page.

The contractors shall use reason code ‘A7’ “Presumptive Payment Adjustment” in the reason code, RC, field to reflect the forced balancing amount in the SPR. 

What is the WIC presumptive payment system?

Presumptive payment uses a direct deposit system called ACH (Automatic Clearing House) to reduce - paperwork and processing time for many checks. One reason that WIC checks are rejected by the bank is due to an “excess dollar amount.” This means that the amount in the “Actual Purchase Price” box on the check is higher than the check’s authorized maximum allowable reimbursement level (MARL). Retailers participating in the WIC presumptive payment system are automatically reimbursed for the full MARL amount if a check is rejected for an excess dollar amount.

How does the WIC presumptive payment system work?

When a check is rejected for an excess dollar amount, the WIC Bank will stamp the check with the message “Excess Dollar Amount – Paid via ACH Transaction” and return it to the retailer’s bank. Every week, the WIC Bank pays retailers by combining their excess dollar MARL reimbursements into a single ACH deposit.

Why would retailers want to use presumptive payment?

The manual process for handling rejected excess dollar paper checks can take a lot of time and effort. It involves correcting the “Actual Purchase Price” on the returned check image to an amount  at or below MARL, and redepositing the corrected check before the deposit deadline. The WIC presumptive payment system provides fast and automatic reimbursements for checks rejected for an excess dollar amount. Currently, over 90 percent of WIC retailers are signed up for presumptive payment

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