Home Health & Hospice Week

Hint: A correct address is vital to avoiding overpayments.

If you ignore a medical review request from AdvanceMed, you're guaranteed an overpayment on that claim - and you risk a run-in with the HHS Office of Inspector General to boot.

Providers that don't respond to a comprehensive error rate testing record request from CERT contractor AdvanceMed within 90 days will find the claim denied, and their carrier or intermediary will recoup the related reimbursement, warned Wayne Steiner, CERT coordinator for Part B carrier HGS-Administrators in Pennsylvania, in a recent Health Care Compliance Association teleconference.

And AdvanceMed could refer such providers to the OIG as well, Steiner added. "Please take this warning seriously," HGS says in a set of questions and answers about the CERT program. "To prevent an error from being charged to the Medicare Program and a fraud and abuse or OIG referral from occurring, please respond to medical record requests from AdvanceMed, send all of the documentation required, and send it timely."

Responding to a CERT request on time is vital, and so is making sure your claim passes medical review. Follow these tips from Mary Mulholland, CERT expert at the Hospital of the University of Pennsylvania, to head off overpayments and OIG referrals:

1. Make a plan. To respond correctly to CERT requests, you must have an effective plan in place. That plan should include designating an employee to coordinate the CERT response, Mulholland said in the HCCA teleconference.

2. Educate employees. Many home care providers say they receive CERT-related overpayments before they even know they had a request, reports the National Association for Home Care & Hospice. That often is the result of incorrect mailing addresses and other communication failures, NAHC says.

Make sure you're getting your CERT requests as soon as they hit the mailbox by educating employees as to what the CERT letter looks like, who the CERT contractor is, etc., Mulholland advised. Then frontline employees can route the letter to your CERT coordinator right away. (To obtain sample CERT letters, email rebeccaj@eliresearch.com with "CERT Letter Request" in the subject line).

3. Ensure the correct address. Make sure AdvanceMed isn't sending your CERT letter to an old or incorrect address. The contractor sends requests to a provider's Medicare "pay to" address, Steiner noted.

Update Medicare whenever you change mailing and "pay to" addresses, enrollment status, location, or phone number, Mulholland counseled. Once Ad-vanceMed has sent you a request once, you can give the contractor a preferred address at which you'd like to receive future CERT requests, she added. Doing so "should decrease the amount of confusion and the delay in your receipt of the CERT request."

4. Clue in your billing company. The high non-response rate to CERT requests last year was due in part to billing companies failing to send CERT requests on to providers.

If a billing company is your "pay to" address, you'll need to coordinate with the company to make sure it recognizes CERT requests promptly and forwards them accordingly, Mulholland instructed.

5. Submit complete documentation. As with any medical review request, make sure the documentation you submit is complete and legible, Mulholland suggested. But with CERT requests, you also receive a bar code page for each record requested. Make sure to attach that page when returning the records.

"I can't emphasize enough the importance of making sure that you keep these forms in a safe place so that when you send the information back to Advance-Med, you're sending back everything that has been requested," she stressed. You should also write AdvanceMed's Claim Identification Number, included on that bar code page, on the top of each page of that patient's record, Mulholland urged.

6. Make copies. Make a photocopy of every single piece of documentation you send to Advance-Med, Mulholland suggested. If you fax in your record, retain your copy of the fax confirmation.

7. Track CERT responses. Internally track your CERT responses, so you can ensure you're re-sponding on time and accurately, Mulholland advised. You can use a tracking form that documents the date you received the request, the date you copied and sent the information, and how you sent it (fax or mail). If you send it via mail, obtain the tracking number, she said.

If you do get slapped with a CERT-related overpayment, you have a couple of options. If you never received the request or didn't respond, you can immediately submit your records to AdvanceMed, NAHC advises. "Once the documentation is received, the carrier or [intermediary] will be told to repay any recovered 'overpayments' to the provider until a further determination is made," NAHC tells its members.

If you know you're running late on a request, inform AdvanceMed that you're working on the response, Mulholland suggested.

Alternately, you can appeal your denial and overpayment to your carrier or intermediary, Steiner explained. "If you receive a denial that you do not agree with, exercise your appeal rights," Mulholland urged.