NPI #’s
CMS finally released the NPI number registry on September 5, 2007 & we have almost finished loading all referring physician NPI #’s in our database. CPB, as has nearly every other practice and billing service, continues to deal with various related minor insurance company NPI # issues. This is because CMS gave every insurance company in the USA (over 2,000 of them!) the latitude to decide when they will require various NPI # & related fields to be sent. So far, all such issues have been successfully addressed.
Refunds
Included with this issue are 2 reprints of articles about East Tennessee Heart Consultants (ETHC) who were fined $2.9 million for not processing insurance & patient refunds. What makes this case significant is that the government used the Federal False Claims statutes against this provider who retained the credit balances of insurers and patients. The False Claims statutes allowed the government to triple the fine against ETHC.
As you know, CPB actively researches credit balances to make sure they are handled properly then sends information to our clients each month indicating:
1. The amount of money to be refunded,
2. Who (patient or insurance) it is to be refunded to, and
3. Why a refund is necessary.
This should ensure that you do not get into this serious problem. Be sure to return your refunds timely. The OIG’s Compliance Guidelines for providers require timely refunds.
More on Insurance Audits
When audits are performed auditors rely on what is documented in the medical record rather than the Charge form. The key point here is that it is critical that what you circle/check off on the Charge form match what you documented as your clinical judgment in the patient’s medical record.
According to a Listserv that I participate in, “60% of the time, that diagnosis is not documented in the medical record.” While I cannot vouch for the accuracy of that percentage, it was made by someone who actively does audits. In an audit, that “disconnect” could lead to tens of thousands of dollars in overpayments. Unfortunately, insurers are less concerned with what's wrong with the patient than what the physician has documented in the medical record.
CMS, Horizon and other insurers actively audit providers often resulting in recouping of “overpayments.” These audits are typically the result of a small percentage of charges (ex., 100 charts) which are extrapolated to the larger # of actually paid charges. The result of one physical therapy practice audit in Florida for 2003 records resulted in an overpayment refund request of over $400,000 (that report was just released by CMS in late August 2007)! Be sure to document properly to ensure you do not get caught in that same situation. If you would like a copy of that report, please let me know.
Sunset of the Physician Scarcity Area (PSA) Bonus Payment
Section 413(a) of the Medicare Modernization Act (MMA) requires Medicare to pay an additional five percent bonus to physicians rendering service in a designated PSA. The bonus payment is based on the amount actually paid, not the amount Medicare approved for each service. The PSA Bonus will no longer be paid after December 31, 2007. Physicians receiving the bonus will receive their last check in early 2008.
Aetna Paper EOB’s to be Discontinued
In some parts of the country Aetna has implemented a plan to discontinue paper EOB’s and paper checks in favor of getting that info only from their website. Payments go to direct deposit to your bank account. If you get such a message from Aetna, you will need to notify CPB immediately so that we know how to obtain your payment information. We also know that Aetna is allowing exceptions and have the procedure to request that exception.
Monday, October 8, 2007
September 2007
NPI #’s
CMS delayed the release of the NPI number registry now until September 5, 2007. We will begin loading NPI #’s as soon as they are available.
QualCare
Effective August 1, 2007 QualCare is the exclusive medical network for Humana commercial health plan members in NJ. QualCare participating providers are now able to serve members from both Humana's local and national accounts. All commercial members who reside in NJ and the surrounding states of Pennsylvania, Connecticut and New York will be identified by all three logos: Humana, ChoiceCare Network, and QualCare. You can obtain the claim preauthorization phone number from the back of the member’s insurance card.
PT/OT Audits
We recently learned that Medicare is beginning to do post payment reviews for PT and OT services. As with all audits, office notes are requested. To ensure no services are denied, Office Notes must be very specific and minutes for each procedure (if a time based) have to be documented clearly.
CMS delayed the release of the NPI number registry now until September 5, 2007. We will begin loading NPI #’s as soon as they are available.
QualCare
Effective August 1, 2007 QualCare is the exclusive medical network for Humana commercial health plan members in NJ. QualCare participating providers are now able to serve members from both Humana's local and national accounts. All commercial members who reside in NJ and the surrounding states of Pennsylvania, Connecticut and New York will be identified by all three logos: Humana, ChoiceCare Network, and QualCare. You can obtain the claim preauthorization phone number from the back of the member’s insurance card.
PT/OT Audits
We recently learned that Medicare is beginning to do post payment reviews for PT and OT services. As with all audits, office notes are requested. To ensure no services are denied, Office Notes must be very specific and minutes for each procedure (if a time based) have to be documented clearly.
Friday, August 3, 2007
August 2007
CPB STAFF OUTING
On Friday, August 17th CPB will be closed for the day to enable our staff to enjoy our annual office Employee Appreciation outing.
NPI #’s
CMS is supposed to make the full NPI # list available online for download as a file on August 1st. We have printed the entire list of referring physicians in the CPB database and will begin loading NPI #’s as soon as they are available.
Zostavax – Not Covered By Medicare
The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Part B Medicare coverage [CMS Internet Only Manual publication 100-2, Chapter 15, Section 50.4.4.2]. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster; and in an immunocompromised state, the vaccine is contraindicated and should not be administered. The vaccine (but not the administration) may be covered under the Part D (prescription drug) Medicare benefit. In such cases it is a non-covered service and can be collected from the patient on the date of service. Posted by CMS on 07/25/2007.
CMS CERT Audits
Providers Nationwide recently received requests for charts as part of the Comprehensive Error Rate Testing (CERT) by Medicare. The auditor is independent of all carriers. We are not aware of any CPB clients that received such a request. However, if you received one, be sure to review the records prior to sending them to Medicare. When you do, look at them from the perspective of auditor – is it clear what you wrote? Is it legible and does what was written makes sense? The auditor isn't familiar with the patient or your style of documentation.
Some things the auditor will look for:
-Does the documentation support the services & level of services billed?
-Is the medical necessity for each service clear & concise?
-For those encounters where the key elements in the documentation supported the E/M you billed, was the level of service billed consistent with the nature of the presenting problem in the documentation of that encounter? Or is this a case where there's lots of documentation, but the problem severity isn't articulated in a way that supports the problem?
-Did you bill any procedures? Would someone who knows nothing about you, how you practice, or anything about the patient, be able to say that the documentation of the procedure clearly mapped to the CPT code(s) (and associated modifiers, if applicable) that you billed?
-Was there any part of the encounter that was routine or would otherwise be excluded from Medicare coverage? If so, was it billed to Medicare in a manner to obtain the expected denial?
-If the service you provided is one where the carrier has an NCD or LCD, does the documentation support the diagnosis code(s) you submitted that established medical necessity for claims payment?
-If there was a frequency limitation for the service billed, does the encounter reflect that there was sufficient time since the previous encounter for Medicare to consider this DOS a covered service?
Suggestions:
-If there appears to be some gaps in what the auditor needs to know, send a cover letter explaining it for each patient.
-Send the requested information as soon as it is ready and do not miss the deadline. Missing the deadline will raise attention to your audit in unnecessary ways.
-Send it to the address given in the letter – it does not go to the Medicare Carrier for your state.
Be sure to send ALL the requested information. Make sure each page has the patient’s name on it so they cannot get mixed with another patient’s documentation. Each patient’s data should be clipped together neatly. You want that packet of documents to clearly, logically and concisely present the practice's supporting documentation for the encounters under review.
On Friday, August 17th CPB will be closed for the day to enable our staff to enjoy our annual office Employee Appreciation outing.
NPI #’s
CMS is supposed to make the full NPI # list available online for download as a file on August 1st. We have printed the entire list of referring physicians in the CPB database and will begin loading NPI #’s as soon as they are available.
Zostavax – Not Covered By Medicare
The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Part B Medicare coverage [CMS Internet Only Manual publication 100-2, Chapter 15, Section 50.4.4.2]. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster; and in an immunocompromised state, the vaccine is contraindicated and should not be administered. The vaccine (but not the administration) may be covered under the Part D (prescription drug) Medicare benefit. In such cases it is a non-covered service and can be collected from the patient on the date of service. Posted by CMS on 07/25/2007.
CMS CERT Audits
Providers Nationwide recently received requests for charts as part of the Comprehensive Error Rate Testing (CERT) by Medicare. The auditor is independent of all carriers. We are not aware of any CPB clients that received such a request. However, if you received one, be sure to review the records prior to sending them to Medicare. When you do, look at them from the perspective of auditor – is it clear what you wrote? Is it legible and does what was written makes sense? The auditor isn't familiar with the patient or your style of documentation.
Some things the auditor will look for:
-Does the documentation support the services & level of services billed?
-Is the medical necessity for each service clear & concise?
-For those encounters where the key elements in the documentation supported the E/M you billed, was the level of service billed consistent with the nature of the presenting problem in the documentation of that encounter? Or is this a case where there's lots of documentation, but the problem severity isn't articulated in a way that supports the problem?
-Did you bill any procedures? Would someone who knows nothing about you, how you practice, or anything about the patient, be able to say that the documentation of the procedure clearly mapped to the CPT code(s) (and associated modifiers, if applicable) that you billed?
-Was there any part of the encounter that was routine or would otherwise be excluded from Medicare coverage? If so, was it billed to Medicare in a manner to obtain the expected denial?
-If the service you provided is one where the carrier has an NCD or LCD, does the documentation support the diagnosis code(s) you submitted that established medical necessity for claims payment?
-If there was a frequency limitation for the service billed, does the encounter reflect that there was sufficient time since the previous encounter for Medicare to consider this DOS a covered service?
Suggestions:
-If there appears to be some gaps in what the auditor needs to know, send a cover letter explaining it for each patient.
-Send the requested information as soon as it is ready and do not miss the deadline. Missing the deadline will raise attention to your audit in unnecessary ways.
-Send it to the address given in the letter – it does not go to the Medicare Carrier for your state.
Be sure to send ALL the requested information. Make sure each page has the patient’s name on it so they cannot get mixed with another patient’s documentation. Each patient’s data should be clipped together neatly. You want that packet of documents to clearly, logically and concisely present the practice's supporting documentation for the encounters under review.
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