Medicare Compliance & Reimbursement

Industry Notes:

CMS Rolls Out New Medicare Advantage Auditing Plan

CMS has been auditing Medicare Advantage (MA) plans since 2008, so practices may not be surprised to hear that those audits are still taking place. What is new, however, is the fact that CMS recently instituted a new initiative to slash errors in the MA program.

By tweaking the audit methodology in a new way, CMS hopes to recover an estimated $370 million in overpayments. "Fighting fraud, improving payment accuracy, and saving money for Medicare is one of our top priorities," said CMS Acting Administrator Marilyn Tavenner in a Feb. 24 statement. "CMS will use a new method of auditing Medicare Advantage plans that improves program integrity and reflects public input."

If You Made A Claim In The AMA Suit Against UHC, Start Looking For Your Check

If you filed a claim during the legal battle between the American Medical Association (AMA) and UHC, you can expect your check by mid-April.

In early February, a federal judge approved the release of payments in the 2009 settlement against UHC. A total of almost $200 million will be paid out to physicians for 15 years of artificially low payments by UHC for out-of-network health services.

"The truly lasting legacy of this court challenge will continue long after the last physician has received a share of the landmark settlement," said Peter W. Carmel, M.D., president of the AMA, in a statement. "UnitedHealth and other insurers no longer will be able to pull the wool over doctors' and patients' eyes when determining payment rates for out-of-network care."

If you did not file a claim, unfortunately, it is too late to do so. But if you did, you should expect your portion of the settlement by April 15, 2012, according to the AMA Website. If you have questions about the settlement or your payment, you can review the AMA's FAQ about the settlement at www.ama-assn.org/resources/doc/psa/uhg-settlement-faqs.pdf.

Don't Miss the Latest Updates on Incentive Payment Program

If you have a physician or other provider involved in the Primary Care Incentive Payment program (PCIP), your bottom line will see an increase in 2012. Family practice and internal medicine specialists will benefit from a 1 percent gain this year over the RVU amounts they received for participation in 2011.

What it is: The PCIP is an incentive payment of 10 percent of Medicare's program payments to be paid to primary care physicians and non-physician practitioners for services rendered from Jan. 1, 2011 until Dec. 31, 2015. Eligible services fall under CPT® codes:

  • 99201-99215 for office and other outpatient visits
  • 99304-99340 for nursing facility, domiciliary, rest home, or custodial care
  • 99341-99350 for home services.

Get the latest details from CMS online by visiting http://questions.CMS.hhs.gov and searching for "PCIP" or "Primary Care Incentive Payment."

To read more about how CMS intends to calculate the results, visit http://www.cms.gov/Plan-Payment/02_PaymentValidation.asp.

One Payer Formally Confirms Male HPV Vaccine Payment

United Healthcare now covers these vaccinations for males and females ages nine through 26. You can rest easy when filing your HPV vaccine claims for male patients, at least for one national payer, thanks to a recent policy update by United Healthcare.

Pediatric practices have been struggling to collect payment for administering the HPV vaccine Gardasil® to male patients. In its February 2012 "Medical Policy Update Bulletin," United Healthcare announced that "coverage of Gardasil® for males will be effective February 1, 2012," but that claims will not retroactively be adjusted for any services performed prior to Feb. 1.

The UHC coverage is now in effect for both males and females aged nine through 26 years.

To read the full UHC announcement, visit www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policy%20Update%20Bulletins/Policy%20Update%20Bulletins/Medical_Policy_Update_Bulletin_February_2012.pdf.