Medicare Compliance & Reimbursement

Successfully maneuvering the Medicare billing landscape can be a daunting task — even for the most experienced biller. And staying abreast of the latest MAC guidance, form changes, and code revisions can help your practice prevent denials.

Avoid Duplicate Billing to Save Time and Money

Submission of duplicate claims not only delays payment, but can also lead to fraud investigations and put entities at risk to be flagged as abusive billers.

When a claim is processed or is processing, a duplicate electronic claim will reject as a front-end edit upon submission and will be reflected on the 5010 277 CA report with the following claim status codes:

• CSCC: A3 – Return as unprocessable
• CSC: 78 – Duplicate of an existing claim/line

This front-end edit will not catch duplicate claims that are billed in the same batch or a batch of claims submitted a day apart. Often, these duplicate batches of claims are errors resulting from a glitch at the vendor or clearinghouse level. Things to keep in mind to avoid this error:

• Some systems can be set to rebill automatically after 30 days.
• Check electronic data interchange (EDI) software settings.
• Claims may show pending status because NGS or your Medicare Administrative Contractor (MAC) requested additional information by way of an EDI.
• Submitting another claim may produce another Additional Development Request (ADR).

Wait For New Provider Approval, Dodge Reassignment of Benefits Errors

If a group submits claims before the new physician or nonphysician practitioner (NPP) application is approved by NGS or your MAC (Form CMS-855R) and provider transaction access number (PTAN) is assigned, you’ll get a reassignment of benefits ANSI code error that looks like this:

• N290: Missing incomplete/invalid rendering provider primary identifier

If a provider submits a claim before they’re officially linked to the practice, it’s not just the inconvenience of an error that’s at stake. In these instances, the provider is liable, not the patient.

“Once the provider’s application is approved and has an effective date with Medicare, under that group, any claims with dates of service on and after the provider’s effective date may be resubmitted for adjudication. Claims for dates of service outside of the provider’s effective date will not be reimbursed, and the provider is liable for these charges,” explained Lee.

Verify Patient Eligibility

Prior to claim submission, it’s important to verify the patient’s eligibility. Some of the most common eligibility ANSI code errors appear like this on the RA:

• OA-109 – Claim/service not covered by this payer/ contractor, you must send the claim/service to the correct payer/contractor.
• PR-31 – Patient cannot be identified as our insured.
• CO-22 – This care may be covered by another payer, or the patient has insurance that is primary to Medicare.

OA-109: When you see this code, this is most likely a situation where the patient is a Medicare Advantage enrollee. However, CMS has mandated that the provider track down the Medicare Advantage information on their own using NGSConnex, the Interactive Voice Response System (IVR), or the equivalent at your MAC. The NGS call center won’t assist with this. Once it’s confirmed the patient has a Medicare Advantage plan, submit the claim accordingly.

PR-31: The cause of this error usually occurs during patient registration and is often the result of a transposed Medicare Beneficiary Identifier (MBI). Resubmitting the claim with the updated information should resolve the problem.

CO-22: You could see this denial for a couple of reasons. One may be a simple case of there being other insurance primary to Medicare (e.g., health insurance through the beneficiary’s employer, if the patient is still working). In this instance, you should check eligibility files for information on the primary insurer, then submit. Once that is processed, you can then submit the secondary claim to Medicare.

Another possibility for the denial is that the patient is retired but the file hasn’t yet been updated. If it is determined that the patient or spouse is retired, and that insurance should not be the primary payer, you can submit a Medicare primary claim and report the retirement date in Item 11b of the CMS-1500 claim form or the electronic equivalent.

Know That Rejection Is Not the Same as Denial

Claims are rejected when they have missing, incorrect, or incomplete data. You’ll see the code, CO-16, which simply means the claim lacks enough valid information to be processed. The remark code offers additional details.

Because a rejection is not the same as a denial, you cannot appeal a rejected claim. “There is only one way to correct a rejected claim, and that’s to correct and resubmit as a new claim,” said Lee. The following issues are what NGS is seeing most commonly.

• CO-16 – Claim lacks information and cannot be adjudicated
• N822 – Missing procedure modifier
• N382 – Missing/incomplete/invalid patient identifier
• MA27 – Missing/incomplete/invalid entitlement number or name shown on the claim
• MA112 – Missing/incomplete/invalid group practice information
• N105 – This is a misdirected claim/service for an RRB beneficiary

If patient ID information is incorrect, verify the information from the patient’s ID card. If the info you have on file matches what you originally submitted, it’s possible the patient’s information has changed recently but was never updated in your records.

If the patient is a railroad beneficiary, submit the claim to MAC Palmetto GBA.

Resolve the Issues Effectively

Monitor the status of the original claim: Using tools, such as NGSConnex, IVR, or your MAC’s equivalent, is an easy and time-efficient alternative to verify whether a claim has been denied, rejected, is pending, or has been approved to pay. Remember, if you see the claim has been denied, do not resubmit without first appealing or reopening the original denial; resubmitting without appealing or requesting a reopening of the original denial will simply cause a duplicate denial.

Reopen or redetermination: To fix a minor clerical error, such as a transposed number, reopening the claim is all that is needed. “A redetermination is used for more complex issues that require review of medical documentation. Keep in mind that rejected claims are not afforded appeal rights. The only way to correct rejected claims is to submit as a new claim,” reminded Lee.