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May 2010 Client Newsletter

Medicare Timely Filing CHANGE

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program. Under the new law:

· Claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service.

· Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules.

· Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010.

Timely Response to

Medicare Medical Review Documentation Requests

Provider Bulletin from Medicare, April 5, 2010: “Highmark Medicare Services… has determined that providers are not responding to our Additional Documentation Requests (ADRs).

When an ADR is received from either Highmark Medicare Services or the CERT Contractor, please be advised that it is your legal obligation to respond to requests for medical records per the SSA. Once you receive an ADR, all records that support the medical necessity of the service billed need to be copied and sent within the time frame specified in the development request. Title 42 of the United States Code, Section 1320c-5(a)(3) indicates that a physician is obligated to provide evidence that the service given is medically necessary.

If the records are not received or not received timely, we are not able to validate that the service was completed and therefore, the claim will be denied. Consequences resulting from no documentation can include claims subject to prepay review, a referral to the Office of Inspector General, or other legal avenues. Patient authorization is not required to respond to the ADR.”

It is imperative that you respond to these requests timely – otherwise it raises suspicions that fraud is being committed and they see an opportunity to recoup even more money. There are certain basic things that are looked for in the documentation such as legible handwriting and signatures – and “rules” to follow. CPB would be happy to review these requests to help ensure you do not undergo recoupment and/or pre-payment reviews which will seriously slow down your cash flow.

Medicaid Drugs

Medicaid has stated they are finding errors in the NDC codes being used to bill injectable medications which has lead to overpayments. Codes used to bill medications are J0120 – J9999, and some “Q” codes. CPB has always required the client to either give us the code or a copy of the product to ensure we are billing the correct code for you – if you change your manufacturer please notify CPB so we can update the NDC code being used.

Medicaid is also going to begin on-site audits to verify the drug name, amount given, etc. – PLUS the drug acquisition records. So be sure that your medical records are accurate and complete and that you save all drug purchase invoices. Failure to do so will result in recoupment of any money paid.


Medicare Advantage (MA) plans ask for access to patient records for a number of reasons. Almost all of those reasons boil down to discovering one of two things: were the diagnosis codes submitted:

· Accurate (i.e., properly documented in the medical record), and

· Complete (i.e., all diagnoses documented were submitted).

The circumstances they ask for these records vary. It may be a CMS audit (called a Risk Adjustment Data Validation, or RADV), with potential for huge over-payments levied against the plan based on physician documentation; it can be a plan RADV, so that they can retract these undocumented diagnoses before CMS conducts a RADV, or it can be to ensure that all the documented diagnoses were submitted to the health plan (and CMS) in the first place.

Given that physician documentation does not support the selected diagnosis code more often than not, it's just as likely that chart review will result in loss of revenue to the plan as it is in an increase. When you submit a diagnosis code, you're in effect attesting that this is what is clinically wrong with your patient. The health plan, however, is on the hook to CMS for what you've claimed.

Physicians have a much better understanding of documentation for CPT than they do for ICD-9. So, many health plans conduct RADVs to ensure that what they've received from physicians is accurate. It also allows Health Plans to provide feedback and education to physicians about appropriate documentation.

MA Plans are only required to provide, at a minimum, the same level of services as traditional fee-for-service (FFS) Medicare. For contracted providers, they are not required to follow any of Medicare's fee schedules and often reimburse at a much lower rate than traditional Medicare (even including the patient's co-payment).

These plans often provide more services (e.g., foot orthotics, hearing aids, dental, etc.) than traditional Medicare covers, and may include drug benefits. Traditional Medicare carriers receive a fixed contractual payment to run the Medicare program for a specific area from CMS. Type C carriers are paid by CMS based on a much more complex formula. This often is based on the number of diseases and complexities which are documented in the physician's chart.
The amount of scrutiny on this issue by CMS is immense.
2010 Client Newsletter Archive