2017 Medicare CO 237 reduction

canbrody

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We have come across several ERAs from Medicare and the totals do not all add up from a posting perspective. Any ideas?
For example, allowed amount is $102.44 (this counts the 2% PQRS reduction for the actual fee schedule of $104.53).
The coinsurance = 20% of $102.44 for $20.49
CO-237 is noted as $3.73
CO-253 is noted as $1.61
Payment is $78.70
In doing the math backwards, I found that Medicare is taking 80% of the allowed amount ($81.95) then subtracting the CO 237 different between the fee schedule, billed amount, and CO 237 amount as noted (104.53-102.44-3.73 = $1.64) then doing the 98% federal sequester to get payment.
$81.95-1.64 = $80.31 x 98% = $78.70.
The problem is I cannot find out what the additional reduction is for from all of the CMS PQRS sites. Plus, I have another administrator who is taking a much larger reduction on the initial allowed amount, but the end math appears to be the same.

I am going nuts, any ideas? Auto posting is certainly not balancing on these.
We have administrators all over the country, NOridian, CGS, NGS, Novitas, Palmetto, just to name a few.
 

Pbhatt1

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Firstcoast medicare

Use FCSO website to see what is actual PQRS reduction per payers guideline. www. firstcoast. medicare.com and then Fees schedule look up tool.
 

thomas7331

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This sounds correct to me - the 2% sequestration is not a penalty but a government budget savings, so it applies only to the payments issued by Medicare, not to the fee schedule, and that's the last reduction applied before the check is released - the sequestration won't affect the coinsurance. On the other hand, PQRS is a provider penalty, so it would apply to the fee schedule before calculation of the coinsurance and would reduce the amount that the provider can collect both from Medicare and from the patient or secondary payer. I don't know if that helps clarify it?
 

canbrody

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Thanks everyone for the input. I will look into this further as I am seeing 3 reductions of 2% applied at different parts My bigger issue is that all of the EOBs have to be calculated manually as the proper breakdowns are not noted on the EOB to do automatic payments, adjustments, transfers, etc. (not concerned about the first or third reduction, it's the second one that is causing our CO-237 to not continue with balancing automatically vs. manually.)
 

thomas7331

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It sounds to me like it may be a software or programming issue or system settings problem with your billing system - I'd start with talking to your system support people and see if they can offer any solution for you. Good luck!
 

canbrody

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Thanks...it's not our billing system though, it is the way the actual EOBs are reading from the Medicare vendors. It is so odd, I have never seen Medicare not balance out with their reason codes and allowances correctly.
 
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