Medicare Compliance & Reimbursement

If big-ticket claims are your practice's bread and butter, keep in mind that the OIG is watching carefully.

A string of recent OIG audits shows just how attuned the agency is to high-dollar errors, and demonstrates a possible reason why the Correct Coding Initative's (CCI's) new medically unlikely edits (MUEs) were imposed.

For example, according to the OIG's Jan. 4 audit report of Group Health Inc. (GHI), a Part B payer in Queens County, NY, the agency reviewed 14 "high-dollar" payments to providers (claims resulting in payments of $10,000 or more) -- three of which were made in error, totaling $84,092 in inappropriate payments to providers.

The reason that the OIG found to request that $84,092 back? The "providers incorrectly claimed excessive units of service," but on the dates of service in question (between 2003 and 2005), MUEs did not yet exist to detect such payments.

The OIG cites the following as the three errors that it found with high price tags during the GHI audit:

• One provider billed 780 units of service, despite having performed just one office visit. The error stemmed from the practice's mistake of placing the diagnosis code in the "units" field. "As a result," the OIG noted, "GHI paid the provider $54,594 when it should have paid $70, an overpayment of $54,524. The provider identified and refunded the overpayment prior to our fieldwork."

• Another provider reported 58 units of service for arthrography injections, despite the fact that the practitioner only performed a single injection. In this case, the provider explained that it had accidentally placed its intended modifier code (modifier 58) in the units field. "As a result, GHI paid the provider $16,193 when it should have paid $1,323, an overpayment of $14,870," the OIG noted. In this situation, as in the case above, the practice refunded the overpayment to GHI before the audit took place.

• In the third case, the provider billed 48 units of service, even though it administered only five doses of a chemotherapy drug. "The provider stated that it had miscalculated the doses administered. As a result, GHI paid the provider $16,407 when it should have paid $1,709, an overpayment of $14,698," the OIG indicated. In this example, the practice acknowledged that it had been overpaid, but had not refunded the overpayment as of the time that it was audited.

The OIG performed similar "high-dollar payment" audits of other carriers, such as those in Oklahoma, New Mexico, Missouri and Louisiana, and found similar results in those regions.

"This probably solves the old question of whether to return an overpayment or not," says consultant P.J. Tenwick in Little Rock, AR. "People say that they know they've been overpaid but that they're going to wait to repay it until Medicare requests it, but that's inappropriate," she says. "If you overpay a patient or a supplier $15,000, you would want them to return it. The same goes for the carriers."

This doesn't mean all MUEs are accurate. If Medicare overpays you because of an error on your part, you are bound to return the money. But if you submit a claim for services that you know you are entitled to collect and your carrier denies the service based on its MUEs, you have the right to appeal.

Beginning Jan. 1, HCPCS offers modifier GD (Units of service exceed medically unlikely edit value and represent reasonable and necessary services) to avoid MUE-related denials.

One problem is that providers don't know which procedures are subject to MUEs. Physicians have asked CMS to make the list of MUEs public, but the agency declined, answering that some providers could misuse that list to bill for the maximum possible number of units of a particular code, says consultant Jay Neal in Atlanta.

Tip: Scrutinize your explanations of benefits (EOBs) to look for remark code N362. This remark code represents units of service "exceeding an acceptable maximum" and may mean your claim has fallen afoul of the MUEs.

Likewise, if you scrutinize your EOBs and find that you were paid for several units of an E/M code or other obvious error, let your payer know that it overpaid you, and refund the excess reimbursement.