Medicare Compliance & Reimbursement

You know just where to list your NPI on your Medicare claims and you have your PTAN handy whenever you call your MAC about a billing issue. But do you know the difference between these two identifiers, and why they both exist? Many providers don’t — and the Centers for Medicare & Medicaid Services (CMS) aims to clear that up in MLN Matters article SE1216, which the agency revised last week.

NPI: The National Provider Identifier (NPI) is distributed by CMS and is a unique 10-digit number that identifies your provider to the Medicare program. You’ll list the NPI on your claims and share it with other providers who need it to bill claims that you refer or order. If you’re part of a group practice, you’ll probably have one NPI for yourself and another for your actual organization.

PTAN: The Provider Transaction Access Number (PTAN) is a number that your MAC assigns you when you contract with it. You’ll use the PTAN to authenticate who you are if you contact your MAC with any questions (such as those about billing or payments). You typically won’t use the PTAN with CMS, but instead will use it with your local MAC.

Resource: For more on this issue, check out MLN Matters article SE1216 at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1216.pdf.

Unnecessary Services Lead to Criminal Charges for Cardiologist

An Ohio cardiologist is under fire for allegedly performing catheterizations, tests, stent insertions and other procedures that weren’t medically necessary to the tune of $7.2 million. The 55-year-old doctor was indicted on 16 counts of federal charges, including health care fraud and making false statements stemming from the charges.

“The charges in this case are deeply troubling,” said U.S. Attorney Steven M. Dettelbach in an Aug. 21 statement. “Inflating Medicare billings alone would be bad enough. Falsifying cardiac care records, making an unnecessary referral for open heart surgery and performing needless and sometimes invasive heart tests and procedures is inconsistent with not only federal law but a doctor’s basic duty to his patients.”

The doctor is accused of upcoding his services, performing unnecessary nuclear stress tests, falsifying test results to justify catheterizations, performing stent insertions on patients who did not have symptoms of a blockage, and other charges that led to the indictment. He is accused of overcharging by $7.2 million and actually collecting $1.5 million.

To read more about the case, visit www.justice.gov/usao/ohn/news/2014/21augpersaud.html.

AHA Asks HHS to Halt OIG Audit Practice of Extrapolation

Nobody likes to get audited by the OIG, but the American Hospital Association (AHA) has taken its disdain for these audits up a notch by formally asking HHS Secretary Sylvia Burwell to rethink the way it calculates Medicare errors when completing audits.

The AHA believes that extrapolation — using a small sampling of claims to calculate an error rate, and then using that error rate to estimate the complete misbilled amount among the entire entity’s charts — is a flawed system, and would like it to be eliminated, wrote the AHA’s Executive Vice President Rick Pollack in an Aug. 21 letter to Burwell.

“The OIG’s approach grossly exaggerates estimated Medicare overpayments, leads to excessive recoveries by Medicare contractors, and otherwise prejudices and burdens hospitals,” Pollack says in the letter.

To read more about this issue, visit the AHA’s website at www.ahanews.com.