General Surgery Coding Alert

Avoid billing-cycle issues with payers.

When the checks cross in the mail and you end up with too much money in your pocket, you better know what to do with it.

Keeping that overpayment for a surgical procedure is not an option. Make sure you have a plan to avoid short changing payers or patients and possibly setting your practice up for fines and fraud allegations.

Read on to get the scoop on what you need to do — and when you need to do it — to stay compliant and keep payers happy.

Identify the Overpayment

Your practice should have an overpayment protocol. “Whether you do your own billing or you have a billing company doing it, your month-end processes should involve running a report of your credits,” says coding expert Barbara Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

When your protocol identifies an overpayment, go over all the details of that claim. Be certain that it isn’t the result of a payment-posting mistake or other error before you contact the payer. This close review will also help you to avoid making similar mistakes in the future.

Question payers: If you get a refund request from a payer, don’t automatically assume that it’s accurate. Instead, investigate the reason for the possible overpayment and determine if the request is timely and for valid reason that warrants a refund.

Document Process With Payers

The first step after identifying an overpayment is communication. Get in touch with the payer to verify the claim and learn how it handles credit balances. Most Medicare contractors use a standard refund form for all overpayments.

For other payers, use a letter to ask for written instructions on where and how to send the refund check. “When you just send them a check, most of the time you’re in for a nightmare,” Cobuzzi says. “The check may not even get cashed and it goes into a black hole, because if they didn’t ask for money back, they don’t know how to handle it.”

When the payer sends you a formal request and you send them a check in return, be sure to include an explanation of what the check is for, along with copies of any EOB forms. Send it by certified return receipt mail, and address it to the repayment staff member at the payer. This creates a full paper trail so that you can prove you identified and refunded the overpayment.

Don’t Mess With Medicare

The OIG is very clear in its compliance guidance for both physicians and third-party billers. By law, all healthcare providers must refund any overpayments they discover. CMS, which previously had a three-year limit on requesting refunds, now has a full five years to do so.

In general, you should refund government payers as soon as possible to avoid potential penalties. Even if you disagree with the decision, you should refund as requested and then appeal the decision. If you don’t Medicare will charge interest on the overpayment and take it from future payments.

Penalty: New regulations state that if you owe Medicare a refund, any new practitioners in your practice who apply for Medicare enrollment will be denied until you pay the money back.