Medicare Compliance & Reimbursement

When it comes to Medicare enrollment, CMS certainly likes keeping providers on their toes. Our article 3 Mistakes Could Derail Your Medicare Enrollment offered snippets from CMS transmittal 292, dated June 12. In the transmittal, CMS listed over a dozen mistakes that providers might make that would cause their carrier to immediately return their enrollment application -- including submitting your CMS-855 enrollment form too early.

But this week, CMS changed course, re-releasing the transmittal as a blank document other than a headline indicating that the change request "is being rescinded and will be reissued at a later date."

Practices continue to keep their fingers crossed that the scheduled revision to the transmittal includes fewer impediments to Medicare enrollment and more tips on how to keep enrollment moving quickly -- but that remains to be seen.

• Modifier misuse allegations might be partly responsible for one physician's legal troubles. A New Jersey practice allegedly overbilled Medicare by almost $5 million by fraudulently reporting lymphedema procedures to its carrier.

Although the practice billed for surgery that the physician personally performed, investigators charged that unsupervised physical therapists, licensed practical nurses, and massage therapists were performing physical therapy services on the patients rather than surgeries.

The attorneys allege that the physician certified that the services were medically necessary, and used inappropriate modifiers and CPT codes to report multiple procedures within a short time period, according to a July 14 press release from the N.J. Office of the Attorney General.

To read the complete press release, visit visit www.nj.gov/oag/newsreleases09/pr20090714b.html.

Don't overlook these important competitive bidding proposals in the physician pay rule. Whether you participate in the upcoming relaunch of Medicare competitive bidding or not, the program set to take effect in 2010 could give you some extra burdens.

In the Centers for Medicare & Medicaid Services' latest physician fee schedule proposed rule, CMS floats beneficiary notice requirements for all durable medical equipment suppliers in bid areas. Under the bidding program, a grandfathering clause allows suppliers that are currently serving patients to continue furnishing DME and oxygen equipment. Suppliers should remember there are limitations to the grandfathering clause, including that it lasts only as long as a capped rental item's last month.

Old: Previously, CMS told suppliers they could pick and choose which items to grandfather.

New: Now, CMS wants to require that if a supplier chooses to grandfather for an item, it must also continue furnishing all rented items in the same product category, according to the proposed rule published in the July 13 Federal Register.

CMS also proposes a requirement for suppliers to notify beneficiaries whether they choose to grandfather or not. A written notice stating the supplier's intention would have to go to the beneficiary 30 days before bidding's start date.

Plus: Suppliers who choose not to grandfather would have to make two phone calls to the beneficiary before picking up equipment -- one 10 days prior to pick-up and one two days prior to pick-up, CMS says.

In the rule, CMS also proposes a method for suppliers who won Round 1 contracts to recover some of their bidding related losses. Under the new provision, they could request payment for damages from CMS due to the program's last-minute cancellation of Round 1 bidding.

Caveats: CMS would make the decision on whether damages were warranted and that determination would be un-appealable. Also, subcontractors wouldn't be eligible for such payments. Suppliers can submit comments on the proposals until Aug. 31.

Resources: Fact sheets about the new proposals are online at www.cms.hhs.gov/DMEPOSCompetitiveBid/02_Federal_Regulations_Notices_and_Manual_Instructions.asp under the "Downloads" section. A link to the physician fee schedule rule is under the "Related Links" section on the same page.