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CMS is often asked about other claim types that may be affected by a full inpatient denial and if the RACs will deny other claim types associated with the inpatient stay, such as physician evaluation and management services. At this time the RAC will not automatically deny claims that are associated with a full inpatient denial. However, these claims may be reviewed individually and there may be a need to fully/partially adjust the claim based on the documentation submitted.
April 6-13 Issuances: OIG issues reviews of high-dollar claims, CMS updates FAQs
OIG reviews high-dollar payments for Medicare outpatient claims processed by TriSpan for the period January 1 through December 31, 2004
On April 9, the OIG released a review of high-dollar payments for Medicare outpatient claims processed in 2004 by TriSpan Health Services, a Medicare fiscal intermediary. Of the 16 payments of $50,000 or more that TriSpan made to providers for outpatient services during 2004, the OIG found that only one was appropriate. TriSpan overpaid two providers $767,000 on 15 claims.
OIG reviews of high-dollar payments for inpatient services processed by NGS in certain states for calendar years 2004 through 2006
On April 6, the OIG released a review of high-dollar payments for inpatient services processed from 2004–2006 by National Government Services (NGS), a Medicare fiscal intermediary, in Illinois, Indiana, Kentucky, and Ohio. The OIG found that of the 303 high-dollar payments NGS made to hospitals for inpatient services during these years, 39 were appropriate. The remaining 264 payments included net overpayments totaling $7.4 million.
Frequently asked questions
CMS released several new/updated frequently asked (FAQ) questions last week related to Medicare fee-for-service payment.
Q. Do we include a copy of the Advance Beneficiary Notice (ABN) with the claim form?
A. No, do not submit a copy of the ABN unless requested to do so by the carrier.
Source: Centers for Medicare & Medicaid Services
OIG issues review of oxaliplatin billing at Baptist Hospitals of Southeast Texas for calendar years (CY) 2004 and 2005
On March 20, the OIG issued a review of oxaliplatin billing at Baptist Hospitals of Southeast Texas for CYs 2004 and 2005. During this time, Baptist actually provided the drug darbepoetin rather than oxaliplatin, for which it billed, on two dates of service and could not support that it had provided oxaliplatin to the beneficiary for two other dates of service. Baptist received overpayments totaling $63,000 for the four dates of service.
OIG issues review of high-dollar payments for Medicare outpatient claims processed by TrailBlazer Health Enterprises for the period January 1 through December 31, 2004
On March 20, the OIG issued a review the outpatient high-dollar payments issued in 2004 by Trailblazer Health, a Medicare fiscal intermediary. The OIG found that of the 17 payments of $50,000 or more that TrailBlazer made to providers for outpatient services during 2004, five were appropriate. TrailBlazer overpaid providers for 12 claims, resulting in overpayments totaling $1.1 million.
Frequently asked questions (FAQ)
On March 18, CMS released several new/updated FAQs related to Medicare fee-for-service payment.
CMS issues memo on proposed cytology proficiency testing under CLIA
On March 13, CMS issued a memorandum related to its recently proposed regulations aimed at assuring the competency of those conducting the most common screening test for cervical cancer.
CMS issues updated interim guidance regarding the temporary mid-level staffing waiver for RHCs
On March 13, CMS issued a memorandum to provide updated guidance regarding the temporary mid-level staffing waiver for RHCs. The memo supersedes SC-09-14, issued November 21, 2008. This update will reduce burdens on existing RHCs resulting from the 1998 policy.
Last week, CMS published Transmittal 1695 to the Claims Processing Manual, reaching back to FY 2006 to include Medicare Advantage (MA) Plan members in the Disproportionate Share Hospital (DSH) calculation. CMS calculates a DSH adjustment to DRG payments for hospitals serving a disproportionate share of low income patients.
By regulation, low-income patients include certain Medicaid patients (Medicaid portion) and certain Medicare patients (Medicare portion). The Medicare portion is a ratio of Medicare Part A patients receiving Social Security Income (SSI) (disabled) divided by the total Medicare Part A patients. The Medicare portion includes MA members because they are eligible for Medicare Part A, even though the payment is being made through a MA plan. The effect of including MA members may be positive or negative for hospitals, depending on how the addition of the MA members affects the overall Medicare portion ratio.
This issue may sound familiar because in July of 2007 CMS published Transmittal 1311 that gave instructions for hospital to include MA members in their Disproportionate Share calculation for FY 2007. Transmittal 1695 requires hospital who received DSH to go back as far as FY 2006 and submit MA plan member data. The affected providers have a limited time frame to submit the claims data for FY 2006: from the implementation date, July 6, 2009, through November 30, 2009.
The process for submitting MA member data entails submitting a separate claim to the MAC/FI with condition code 04 (Information Only) and the Medicare Beneficiary’s HICN. CMS has instructed contractors to override timely filing edits for these claims. They have also turned off the Medicare Summary Notice to the patient.
NOTE: Teaching hospitals are not affected by this requirement because they would have already submitted a claim for Indirect Medical Education payment with condition code 04 and 69, which would allow CMS to account for the MA plan members in their DSH calculations.
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A procedure code listed in an OIG report about services that are often not medically necessary
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A diagnosis code that a RAC believes, based on knowledge from work in the private health insurance arena, facilities may incorrectly code
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A provider with a high utilization rate compared to other physicians or states
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A belief that the claim payment was inconsistent with Medicare payment policy
CMS clarifies policy on reopening claims
On January 16, CMS issued a transmittal clarifying what constitutes new and material evidence as good cause for reopening a claim.
Effective date: February 16, 2009
Implementation date: February 16, 2009
CMS corrects errors in previous OPPS update transmittal
On January 16, CMS rescinded and replaced its previous transmittal updating the OPPS for 2009. CMS made minor changes to the transmittal’s verbiage; most information remains the same.
Effective date: January 1, 2009
Implementation date: January 5, 2009
CMS updates: Contacting CMS in regards to RAC-reviewed claims and RAC ODF transcripts
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