Part B Insider (Multispecialty) Coding Alert

Published on Thu May 12, 2005 PDF

And Ban on Resubmissions of Denied Claims Causes Headaches

Physicians are facing denial rates as high as 50 percent due to the new Medicare requirement to match patients' names and other identifiers to their Medicare cards, providers claimed in Medicare's June 7 Physician Open Door Forum.

In some cases, providers may have the patient's correct name, but the patient is enrolled in Medicare without a middle initial. Some online databases may provide incorrect information, stymieing providers who haven't had access to a patient's Medicare card directly. Some patients may have registered with Medicare under a nickname, such as "Bobby," which they've used for decades.

Officials with the Centers for Medicare and Medicaid Services say they're looking into the issue, but didn't make any promises. They claim they added the edit because providers were billing for services they actually provided to a different patient, or didn't provide at all. In many cases, married patients or twins can have similar names as well as Medicare numbers that only differ in the final letter.

Physicians could face as much as a 30 percent cut in their Medicare reimbursement as a result of this edit, one provider told the Forum. Untangling these errors could also cost physician practices a lot of money and force them to sic collection agencies on patients.

During the Forum, CMS officials also revealed that:

 CMS is looking into the impact of a recent transmittal (Change Request 3622), which said Medicare would no longer allow re-review of previously denied claims. Sometimes, a claim will have associated multiple diagnoses, and the physician will submit the claim with the wrong diagnosis and then want to resubmit the claim with the correct diagnosis, one provider said. In the past, you could resubmit these claims electronically, but now the carriers are saying they'll require manual redetermination. CMS officials promised they'd have a detailed response to this concern soon.

 The Medicare Replacement Drug Demonstration project will cover drugs for all patients with recurrent breast cancer, as well as patients with breast cancer of stage two to four. The demonstration has enrolled over 29,000 people but still has lots of room for more, CMS officials said.

 You can apply for a national provider identifier (NPI) now, but the carriers will notify you when they're ready to start accepting them in health care transactions. The carriers must accept NPIs by May 23, 2007 and private insurers must accept NPIs by May 23, 2008.

 The carriers can decide whether to let you bill for concurrent infusion if you mix both infusions in a single bag, CMS officials clarified.