Medicare Compliance & Reimbursement

If you bill United Healthcare (UHC) on behalf of your Medicare patients, the rules just got tougher.

Starting in the third quarter of 2008, only accredited outpatient imaging facilities and physician offices will be able to collect reimbursement from UHC for certain CPT codes (a list of which are available on UHC's Web site at http://www.unitedhealthcareonline.com).

"Currently, only approximately half of the plan's MRI, nuclear medicine, and CT providers are accredited, while nearly two-thirds of PET providers have completed the accreditation process," according to a recent statement from the American College of Radiology.

To begin the accreditation process, UHC directs imaging facilities and practices to the American College of Radiology or Intersocietal Accreditation Commission Web sites (http://www.acr.org or http://www.intersocietal.org).

• The OIG zeroed in on hospital outpatient services recently, and the results were eye-popping.

According to a new audit report, released last week, the OIG reviewed high-dollar hospital outpatient claims in California between 2003 and 2005, and found that the government overpaid $3.5 million to these providers.

The OIG audited 59 high-dollar payments (payments totaling $50,000 or more) and found only 18 that were paid appropriately. The remaining 41 included such errors as excessive units of service, often in combination with the wrong HCPCS codes.

For instance, Medicare overpaid one particular medical center for 11 claims that stemmed from a "mapping error" in its pharmacy billing system, which miscoded two drugs' HCPCS codes, resulting in overpayments of $575,000.

All of the medical centers involved in the audit have already reimbursed Medicare for the overpayments.

To read the audit report, visit http://www.oig.hhs.gov/oas/reports/region9/90700059.pdf.

• Your local Medicare contractor could soon adopt fraud-fighting practices from other contractors around the country.

Infusion therapy fraud in South Florida has encouraged intermediaries and carriers to work together on fraud schemes that spread from one region to another, CMS notes in March 7 Transmittal No. 326 (CR 5725).

For more information on the fraud-fighting initiative, visit http://www.cms.hhs.gov/transmittals/downloads/R326OTN.pdf.