Medicare Compliance & Reimbursement

Are computer glitches eating your reimbursement?

You need to be vigilant for computer billing problems at your carrier and other Medicare contractors, say experts. As long as Medicare uses computers, you suffer from technical errors -- but you can ease the headaches if you catch goofs early.

Medicare recently owned up to a big computer problem, but there's no way of knowing how many other errors the carriers haven't detected yet, say experts.

Gremlins in the system caused Medicare contractors to identify some patients incorrectly as belonging to Medicare managed care plans, the Centers for Medicare & Medicaid Services (CMS) announced in MLN Matters article SE0681. Between 150,000 and 300,000 claims were denied incorrectly, and the contractors started collecting overpayments.

What went wrong: During the week of Dec. 17, 2006, Medicare updated its systems with "some incorrect managed care enrollment data," which led to incorrect denials, CMS explains.

What next: You don't have to do anything about these claims, CMS insisted. The contractors will fix the problem on their own and repay you any money they took back by mistake.

"We like to think once we click the send button and it's off, our payment is coming," says Crystal Reeves with The Coker Group in Alpharetta, GA. "The more I work in a billing office, the more I see it's not the case." If you're not vigilant, your claims can disappear into your carrier's computers, never to be seen again.

What to do: Reeves recommends going back and doing a "spot check" on claims for each payor 40 days after you submit them. Most payors will pay clean claims within 30 days, so if you see a bunch of claims from one payor or carrier that haven't been paid, that could indicate a problem. Sometimes, all the claims you submitted on one particular date could have gotten lost, she says. Call your carrier rep and ask if her or she has received a particular claim.

Also, just because one big, well-publicized computer glitch is being addressed -- like the managed-care one -- don't relax your vigilance. "There may be other glitches that we haven't caught because we're attributing everything to that one event," Reeves says.