Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 14, 2006 PDF

$4,000 extra charge leads to more than $65,000 in damages

-Balance billing- led to a plastic surgeon being knocked off balance.  Connecticut surgeon Charles Gianetti treated Allison Siglinger for her injuries in an automobile accident and received $1,980.80 from her insurance company.

When Siglinger's parents requested some of Gianetti's records for a lawsuit they were filing, Gianetti tried to bill them $4,496.20, which he said was the balance they owed after the insurer had paid its share. Gianetti claimed their request for records had entitled him to bill the Siglingers separately.

A court ruled against Gianetti and awarded $39,970 in actual and punitive damages to the Siglingers and $25,656.30 to their attorney. The court ruled that based on other lawsuits arising out of Gianetti's practice of -balance billing,- he was aware that court decisions and statutes banned this practice. Gianetti appealed and the Connecticut State Supreme Court affirmed the decisions against him.

In other news:

- Medicare Part B premiums will hit almost $100 next year, Centers for Medicare & Medicaid Services (CMS) head Mark McClellan said July 11, according to the Cleveland Plain Dealer. And the 11-percent increase to $98.40 does not include any costs of rescuing physicians from next year's slated 5.1-percent payment cut, McClellan added.

- Apalachicola, FL physician Thomas Merrill was sentenced to life in prison for causing patients- deaths by over-prescribing morphine, oxycodone and other painkillers. A jury convicted Merrill of 98 counts of wire fraud, health care fraud and distribution of controlled substances. Prosecutors say 80 percent of the 300,000 prescriptions he wrote from 2001 to 2004 were for controlled substances.

- Your prospective patients may soon be able to see through you, if other payors follow Aetna Healthcare-s example. Aetna is rolling out -transparency- initiatives that reveal pricing as well as clinical quality and efficiency information about 70,000 physicians nationwide.

- CMS released revised guidance for national coverage determinations (NCDs) that require providers to capture additional patient data along with standard claims data. CMS hopes the so-called NCD with Evidence Develop-ment will ensure that patients receive appropriate care and also speed up access to new technologies. You can read the new guidelines at www.cms.hhs.gov/coverage.

- Contractor medical review staff should send you a letter which notifies you of the results of postpayment medical review, CMS instructs in Transmittal 149, dated June 30. This letter should include beneficiary information, unless the contractor is aware that you-re no longer occupying a physical address.

- The interest rate for Medicare overpayments and underpayments has gone up to 12.625 percent, CMS says in July 12 Transmittal 101.