Part B Insider (Multispecialty) Coding Alert

Published on Wed Jan 10, 2007 PDF

Part B payments 'vulnerable to fraud,' watchdog says

Nursing homes could be hotbeds of inappropriate billings, warns one government agency.

Your doctor's Part B claims for services to patients who are in a nursing home but not during a Part A-covered stay are -particularly vulnerable to fraud and abuse,- warns the HHS Office of Inspector General (OIG) in a new report (OEI-05-06-00240). Congress has asked the OIG to keep an eye on doctors billing for services that the nursing home may already be billing for separately.

The OIG's new report (-Medicare Part B Services For Nursing Home Residents-) doesn't draw any conclusions. But it does point to a lot of money going to doctors billing in nursing homes, and that may indicate duplicate billings. Medicare paid $5.3 billion for Part B services for non-Part A nursing home patients.

Ten services accounted for 79 percent of these billings. These included -minor procedure,- -nursing home visit,- -lab test,- -specialist- and -standard imaging.- The OIG says it will be looking at these areas and gathering more up-to-date information to figure out how many payments overlapped with services the nursing home billed.

In other news:

- Systems at Palmetto GBA fouled up, causing the carrier to start collecting overpayments through the -offset process.- Normally, when the carrier identifies an overpayment, it sends you a demand letter asking for a refund. If you don't send the money within 30 days, interest begins to accrue. After 40 days, the carrier takes the money back from your other payments.

What went wrong: The carrier began taking back payments from current reimbursement before the 40-day timeline had passed. In some cases, Palmetto says it was recouping payments before the provider had even received notification of the overpayment.

Palmetto says it issued checks on Jan. 26, 2007 for the amounts it took back by mistake. If providers already had other outstanding debts that were more than 40 days old, Palmetto applied the refunds to the outstanding debts.

- Carriers mistakenly listed the professional-component relative value units (RVUs) for new tissue ablation codes 77013 and 77022 as zero, according to the Physician Regulatory Issues Team. Medicare should soon issue a correction notice with the corrected RVUs.

- New mammography code 77055 also had incorrect RVUs for the professional component listed, PRIT says. This code replaced 76090, which had a payment of around $36.38 for the professional component in 2006, but the 2007 RVU file doesn't list a proper PC RVU for 77055. Medicare will soon clarify that the PC reimbursement for 77055 is $33.35.