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October 2007 Client Newsletter

NPI #’s

CMS finally released the NPI number registry on September 5, 2007 & we have almost finished loading all referring physician NPI #’s in our database. CPB, as has nearly every other practice and billing service, continues to deal with various related minor insurance company NPI # issues. This is because CMS gave every insurance company in the USA (over 2,000 of them!) the latitude to decide when they will require various NPI # & related fields to be sent. So far, all such issues have been successfully addressed.


Included with this issue are 2 reprints of articles about East Tennessee Heart Consultants (ETHC) who were fined $2.9 million for not processing insurance & patient refunds. What makes this case significant is that the government used the Federal False Claims statutes against this provider who retained the credit balances of insurers and patients. The False Claims statutes allowed the government to triple the fine against ETHC.

As you know, CPB actively researches credit balances to make sure they are handled properly then sends information to our clients each month indicating:
1. The amount of money to be refunded,
2. Who (patient or insurance) it is to be refunded to, and
3. Why a refund is necessary.

This should ensure that you do not get into this serious problem. Be sure to return your refunds timely. The OIG’s Compliance Guidelines for providers require timely refunds.

More on Insurance Audits
When audits are performed auditors rely on what is documented in the medical record rather than the Charge form. The key point here is that it is critical that what you circle/check off on the Charge form match what you documented as your clinical judgment in the patient’s medical record.

According to a Listserv that I participate in, “60% of the time, that diagnosis is not documented in the medical record.” While I cannot vouch for the accuracy of that percentage, it was made by someone who actively does audits. In an audit, that “disconnect” could lead to tens of thousands of dollars in overpayments. Unfortunately, insurers are less concerned with what's wrong with the patient than what the physician has documented in the medical record.

CMS, Horizon and other insurers actively audit providers often resulting in recouping of “overpayments.” These audits are typically the result of a small percentage of charges (ex., 100 charts) which are extrapolated to the larger # of actually paid charges. The result of one physical therapy practice audit in Florida for 2003 records resulted in an overpayment refund request of over $400,000 (that report was just released by CMS in late August 2007)! Be sure to document properly to ensure you do not get caught in that same situation. If you would like a copy of that report, please let me know.

Sunset of the Physician Scarcity Area (PSA) Bonus Payment

Section 413(a) of the Medicare Modernization Act (MMA) requires Medicare to pay an additional five percent bonus to physicians rendering service in a designated PSA. The bonus payment is based on the amount actually paid, not the amount Medicare approved for each service. The PSA Bonus will no longer be paid after December 31, 2007. Physicians receiving the bonus will receive their last check in early 2008.

Aetna Paper EOB’s to be Discontinued

In some parts of the country Aetna has implemented a plan to discontinue paper EOB’s and paper checks in favor of getting that info only from their website. Payments go to direct deposit to your bank account. If you get such a message from Aetna, you will need to notify CPB immediately so that we know how to obtain your payment information. We also know that Aetna is allowing exceptions and have the procedure to request that exception.
2007 Client Newsletter Archive