Part B Insider (Multispecialty) Coding Alert

Published on Fri Sep 15, 2006 PDF

Utah Court Takes Managed Care Antitrust Claim With A Grain Of Salt

Radiology providers billed Medicare inappropriately for a staggering 100,034 radiology services in 2001-2003, the HHS Office of Inspector General (OIG) warned in a new report (A-01-04-00528).

Medicare overpaid $20 million during that period for services where Medicare Part A covered radiology services, but providers still billed Part B for the technical component (TC) of those services as if they were outpatient services, the OIG said. That meant Medicare paid twice for the same services, the OIG warned.

The Centers for Medicare & Medicaid Services (CMS) should chase down that $20 million in overpayments from the radiology pro-viders, the OIG urges. Also, CMS and the carriers should put into place prepayment edits to make sure they-re not paying under Part B for services that Part A has already covered.

The carriers also should be educating radiology suppliers about the most common payment errors and how to avoid them, the OIG says.

In other news:

- The Tenth U.S. Circuit Court of Appeals ruled Sept. 6 that managed health care company Intermountain Health Care (IHC) didn't violate the Sherman Antitrust Act when it refused to open its provider panel to optome-trists. IHC excluded optometrists after its panel ophthalmologists lobbied the company to keep optometrists out.

IHC's reaction to the ophthalmologists- complaints did not constitute a -concerted action- within the meaning of the antitrust law, the court ruled. Likewise, the optometrists did not present any evidence that IHC and its paneled ophthalmologists colluded in the decision.

Additionally, the appeals court rejected the optometrists- argument that IHC illegally tied the sale of non-surgical eye care to the sale of IHC managed care plans. The court found no case law indicating that managed care companies and the products they sell should be treated any differently than participants and products in other markets. The court agreed with the lower court's conclusion that IHC marketed a single product: -access to health care priced to subscribers and paid to health care providers according to prior arrangements made with those providers.-

The decision is Abraham v. Intermountain Health Care Inc., 2006 U.S. App. Lexis 22658 (10th Cir. Sept. 6, 2006).

- Starting Oct. 1, Medicare will only send electronic remittance advice (ERA) notices that comply with the Health Insurance Portability and Accountability Act (HIPAA), CMS said in MLN Matters Article SE0646.

- Miami physician Zabdy Westerburger received a 46-month prison sentence for her part in a scheme to write prescriptions for fake patients in return for kickbacks, the Sun Sentinel reported.