Medicare Compliance & Reimbursement

Medicare could auto-deny 100 percent of suspicious claims.

Watch out: Medicare's Program Safeguard Contractors (PSCs) will be on the lookout for "high-risk areas" soon.

These are groups of claims with unusual patterns that show a potential for fraud and abuse. Warning signs could include:

· a sudden change in billings,

· a spike in billings,

· the wrong specialty billing for some procedures,

· the wrong diagnosis codes on claims,

· beneficiary complaints, or

· billing for bundled Part B services during a Part A institutional stay.
 
Red flag: Another big warning sign would be a doctor ordering outside services for a patient when the ordering doctor has never seen the patient. Don't let your doctor order services for a patient unless you've already billed for your doctor's own services provided to that patient.

When they find a high-risk area, the PSCs can impose their own edits on your claims, including prepayment medical-review edits. They can also impose automatic denials on 100 percent of your claims, send Medicare Summary Notices (MSNs) more often, check your enrollment status, and work with beneficiaries more closely, according to Transmittal 210 (CR 5626).

In other recent transmittals:

· If your doctor's national provider identifier (NPI) matches up with more than one old unique provider identifier number (UPIN), you could be receiving a barrage of letters from your carrier. That's because the carriers' systems are set up to send you one letter per claim if they can't match up an NPI with one UPIN.

But Transmittal 284 (CR 5621) tells the carriers to update their systems so they only send one letter per day to providers. It's still a really good idea to make sure they can match up each NPI with a UPIN, experts stress.

Meanwhile, the Centers for Medicare & Medicaid Services (CMS) came up with a crosswalk between NPIs and UPINs, to help validate NPIs. In Transmittal 1262 (CR 5649), CMS tells the carriers to contact at least 10-15 providers per week to verify NPI information. The carriers should start out with the providers who have the highest volume of rejected claims due to invalid NPI information, and the providers who aren't submitting NPIs.

· Good news: If you have failed to submit documentation in response to a Medical Review (MR) request, you get a second chance. Instead of forcing you to appeal MR denials for lack of documentation, contractors will allow you to reopen the claim and adjudicate it through the "progressive corrective action" process, according to Transmittal 202 (CR 5246).

· If your physician has to discard an extra portion of a drug or biological, Medicare will pay for the wasted portion, according to Transmittal 1248 (CR 5520). But Medicare will pay for the extra portion [...]