December 2017 Client Newsletter
December 2017 Client Newsletter
CONCEQUENCES OF CREDIT BALANCE REFUND DELAYS
From a November 8th article by MGMA: Repayment delay triggers False Claims Act settlement for double damages
“A cardiovascular group recently agreed to pay over $440,000 to settle false claims allegations that they failed to timely report and return $175,000 in overpayments owed to federal healthcare programs. Under the 60-Day Repayment Rule, healthcare providers must repay credit balances owed to federal payers within 60 days of identifying the overpayment. The government intervened following a whistleblower lawsuit filed by a former employee of the medical group.
This is only the second reported settlement under the 60-Day Repayment Rule; the first resulted in treble damages. These settlements confirm the Department of Justice’s commitment to using the False Claims Act to enforce the rule and underscores the importance for practices to implement policies to identify and report overpayments.”
INSURANCE TIMELY FILING DEADLINES
As a reminder, insurers have timely filing deadlines. While most allow 1 year from the date of service, a few have them as short as 90 days (e.g., Oxford). Be sure you send your charges within a few days of treating the patient.
2018 MEDICARE PART B DEDUCTIBLE
The Medicare Part B deductible will be the same as this year: $183.
COMPLIANCE
When insurers audit, one of the techniques they use is to add the total amount of time required for each CPT E&M code. For instance, CPT codes are assigned “typical” times for “face-to-face time with the patient and/or family:
99213 15 minutes
99214 25 minutes
99215 40 minutes
99203 30 minutes
99204 45 minutes
99205 60 minutes
The auditors then look at the total patients each day, and not just their patients, then total the expected time with face-to-face care. So, if a solo practice office saw 25 or 37 patients a day:
|
Code |
Typical |
Actual Visits #1 |
Total Time |
Actual Visits - #2 |
Total Time |
|
99213 |
15 |
15 |
225 |
20 |
300 |
|
99214 |
25 |
5 |
125 |
10 |
250 |
|
99215 |
40 |
2 |
80 |
3 |
120 |
|
99203 |
30 |
1 |
30 |
2 |
60 |
|
99204 |
45 |
2 |
90 |
1 |
45 |
|
99205 |
60 |
0 |
0 |
1 |
60 |
|
Totals |
|
25 |
550 |
37 |
835 |
|
550 Minutes = 9.2 Hours |
|||||
|
835 Minutes = 13.9 Hours |
|||||
These scenarios suggest it would require over 9 hours of office time for the 1st example and almost 14 hours for the 2nd. Of course, the measurement is not based solely on time, it depends on the written documentation for the levels of history, examination, and medical decision making.
Bottom line; be sure patients are not in a position where they could call and complain to their insurer or State Board of Medical Examiners about the amount of time spent seeing you face-to-face. It can be exacerbated if patients are not seen on time resulting in them being unhappy.
NEW MEDICARE PATIENT POLICY NUMBERS – EFFECTIVE APRIL 1, 2018
This is essentially “Old News.” Patients get new insurance cards all the time, this is just going to be a larger scale. ALL offices and providers should be asking patients if they have new insurances/ addresses /email, etc. at every visit or episode of care.
For those interested, we can send you a PDF from CMS about the new Medicare policy numbers that will be issued to patients starting April 1, 2018. The only requirement for offices will be to get a copy of the new card for each patient and forward it to CPB. We will handle the rest as usual. We do this now when any patients’ insurance changes.
About a year ago we updated our software to make sure the new Medicare policy number format is verified. We do not expect there to be any issues as long as all providers obtain the new insurance cards on the date of service – UNLESS the Medicare MAC’s systems do not function properly. We think there has been sufficient lead time that this is unlikely. As April approaches, we will let you know if we see any issues.
If you have any questions, please give us a call.
UNNA BOOT COVERAGE
When considering an application of an Unna Boot, be aware of the following Horizon policy if the patient has that insurance: “Unna boot is medically necessary for:
1. Venous stasis ulcerations of the lower extremity, and
2. Lower extremity burns as an adjunct to excision and grafting.”
And that’s it. No other diagnoses are covered. Be sure your notes clearly reflect the medical necessity.
Simply stating that the patient has an “open wound” would not meet Horizon’s requirements. Any other diagnosis will result in denial of payment. If you want to be able to bill and collect from the patient, we would recommend obtaining an ABN-like document showing the patient was notified it was not a covered service and accepting financial responsibility. Then collect the money on the date of service. We can still bill Horizon, and if paid, the patient’s payment can be refunded.
AMERIHEALTH ANNOUNCES INTENT TO STOP ACCEPTING CONSULT CODES
AmeriHealth has announced its intent to no longer pay for consultation CPT codes 99241-99245 and 99251-99255 for dates of service on and after January 1, 2018. AmeriHealth is aligning their policy with CMS, which stopped recognizing consultation codes for payment in 2010, but will be the only commercial payer to implement such a policy. Earlier this year UHC announced its intent to implement the same policy but then decided to delay implementation.