Contractors:
KNOW 'WHO'S ON FIRST' IN THE DMAC TRANSITION
Published on Mon Mar 06, 2006
Have you met your Program Safeguard Contractor yet?
As the feds ditch the DMERCs, suppliers will need to keep up with more than just their new DMAC.
Why? The Centers for Medicare & Medicaid Services may see the shift to the new Medicare administrative contractors (MACs) as "simplifying." But in reality the related changes set forth in the Medicare Modernization Act of 2003 call for the introduction of other new contractors with responsibilities other than claims processing. Here's a run down of who's charged with what task:
Instead of having a DME regional carriers handle all claims functions for each region, the following functions will be split among three different types of entities: the DMAC, the Program Safeguard Contractor (PSC) and the Qualified Independent Contractor (QIC).
Your DMAC. Your DMAC will be your key claims-processing partner. "For claims that do not need medical review and do not need to be appealed, you only deal with this contractor," explains Kathy Dodson of the government affairs division of the American Orthotic & Prosthetic Association in Alexandria, VA.
Though CMS awarded DMAC contracts to four organizations on Jan. 6, providers are waiting to see if the original contracts hold, especially in Regions C and D (see Eli's HCW, Vol. XV, No. 13).
DMAC contracts issued by CMS so far assign National Heritage Insurance Company as the contractor for Region A, AdminaStar Federal for Region B, Palmetto GBA for Region C and Noridian Administrative Services for Region D. Your PSC. The PSCs, which assumed their new responsibilities in March, will develop medical policy and conduct medical reviews. They will also be key in ferreting out fraud and abuse, since medical directors and others on staff will be responsible for developing and maintaining "benefit integrity."
Know the process: How will the PSC in your region work with you? If you have a claim requiring medical review, the DMAC will forward the claim to the PSC. After gathering information and required documentation, the PSC will make a medical necessity determination and forward the claim back to the DMAC for processing.
TriCenturion of Columbia, SC is the PSC for DME Regions A and B. TrustSolutions, based in Milwaukee, is the PSC for DME Region C. And Integri-Guard, based in Omaha, NE, is the PSC for Region D. Your QIC. The QICs will take on the task of helping the DMAC with appeals. The DMAC will handle first-level appeals. The QIC responsibility will kick in on second-level appeals. CMS has named only one QIC for DMEPOS claims, Q2Administration, a Palmetto subsidiary. Don't Let Redefined Regions Trip You Up As CMS transitions to the new claim-processing system--as soon as July 1--it will slightly redefine the existing four regions (A, B, C and D).
Though most providers won't [...]
