Medicare Compliance & Reimbursement

If your reimbursement seems too good to be true, it probably is.

Two providers that were recently audited by the HHS Office of the Inspector General (OIG) didn’t seem to notice that they were paid more than double the reimbursement that they should have collected. However, you can rest assured the government will certainly notice the mistake if you overbill in your HCPCS code assignments.

The case: The OIG launched an audit of aflibercept, a drug used to treat patients with age-related macular degeneration, and found that CGS Medicare paid $6 million for 1,414 line items for this medication using code Q2046 (for dates of service in 2012) or J0178 (which was assigned to the code in 2013). The average payment for treatment with aflibercept is approximately $1,960 — so the OIG realized that at least one of the providers included in the audit was overbilling.

A deeper review revealed that six line items, billed by two different providers, accounted for total payments of $1.77 million for aflibercept. In addition, the claims didn’t have macular degeneration listed as the diagnosis, and the unit numbers far exceeded the recommended dosage of two mg of the drug.

The Problem? A Wrong Code

The providers in question said that they accidentally assigned the wrong HCPCS codes to their claims because they actually meant to report the codes for ziv-aflibercept, a drug used to treat metastatic colorectal cancer. It’s unclear, however, how they failed to notice that they were paid more than double the reimbursement that they should have collected.

What’s even more surprising was that CGS appeared to notice the issue before paying the practices and froze the payments. CGS had contacted the practices to confirm that the correct line items were reported. The practices all confirmed that they had billed correctly (even though they hadn’t), after which CGS paid them.

The takeaway: If your reimbursement seems too good to be true, it probably is. If you’re ever contacted by your payer and asked to confirm a line item, double-check that you billed properly before responding. If you end up getting paid substantially more than you typically would for an item or service, do some research to ensure that you billed everything properly and that no mistakes were made, either by the payer or by your office. Otherwise, you’ll be facing paybacks down the road.

Resource: To read the complete OIG report, visit, http://oig.hhs.gov/oas/reports/region6/61400053.pdf.