Medicare Compliance & Reimbursement

If your payer is performing a pre-payment audit of your claims, the MAC will typically ask you for additional documentation. In the past, some MACs would say you had 30 days to submit the documentation, while other insurers might not have given you a timeframe at all. CMS has cleared the air on this topic, confirming that you have 45 days to respond to an Additional Documentation Request (ADR), the Centers for Medicare & Medicaid Services’ (CMS) says in MLN Matters article MM8583, issued on Nov. 14 and effective on April 1, 2015. On the 46th day after the MAC requests the documentation, your claim will be denied if you haven’t sent the requested materials.

Unfortunately, if you’re in a bind and unable to meet the 45 day threshold, CMS does not appear likely to give you more time. “The reviewer should not grant extensions to providers who need more time to comply with the request,” CMS says in Transmittal 554, also issued Nov. 14. “Reviewers shall deny claims for which the requested documentation was not received by day 46.”

To read the MLN Matters article on this topic, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf. For the transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R554PI.pdf.

CMS Reminds Practices of ‘GW,’ ‘GV’ Modifier Requirements

Recent RAC audits revealed a disturbing trend that CMS would like to see end soon, and it involves physicians billing for care of hospice patients. The topic is outlined in new MLN Matters article SE1321, issued recently.

Background: Services related to your care of a hospice patient’s terminal diagnosis are included in the hospice payment, and are not separately billable. Part B will deny any claims submitted for the patient’s terminal care because the payment is already bundled into the payments CMS makes to the hospice.

If, however, you are not employed by the hospice or your services are unrelated to the terminal diagnosis, you can bill separately, if you use the appropriate modifier.

If the provider is not employed or paid by the hospice provider even though the services are related to the patient’s terminal diagnosis, you can use modifier GV (Attending physician not employed or paid under arrangement by the patient’s hospice provider) to bill separately for your claims. If, however, your services are completely unrelated to the terminal prognosis, you should opt instead for modifier GW (Service not related to the hospice patient’s terminal condition).

For example: A hospice patient with pancreatic cancer presents to an orthopedic surgeon for treatment of a metatarsal fracture. The orthopedist can report 28470-GW to reflect that his services were unrelated to the patient’s cancer.

Resource: To read the complete article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1321.pdf.

OIG Keeps Pressure On Home Health, Hospice

Don’t expect to say goodbye to the headache-inducing face-to-face physician encounter requirement any time soon as the HHS Office of the Inspector General (OIG) considers F2F a fraud-prevention measure.

In its latest “Top Management & Performance Challenges” report, the OIG highlights home health as an area with high improper payment rates and a “known … fraud risk area.”

The OIG pats itself on the back for using the face-to-face physician encounter requirement as a fraud prevention tool. It also notes that rates of improper billing have gone down after instituting a temporary moratoria on HHA enrollment in fraud hot spots such as Miami.

The watchdog agency throws a spotlight on hospice fraud concerns as well, listing “insufficient monitoring of hospice service use, as well as inadequate oversight of hospice certification surveys and hospice-worker licensure requirements.”

The OIG lauds hospice fraud-fighting measures including ramping up hospice quality reporting and starting work on hospice payment reform. It also praises the IMPACT Act’s new requirements that Medicare survey hospices at least every three years and increase medical review of hospices with long-stay patients.

See the report at http://go.usa.gov/sNTF.

Physicians Allegedly Took Kickbacks as Incentives to Use Cardiac Products

If a medical supplier offers you a financial incentive to use its products, turn around and walk the other way, because the OIG is watching and it’s not worth the risk.

That’s the takeaway from a recent case involving Biotronik Inc., which paid $4.9 million last week to resolve accusations that it paid kickbacks to doctors to encourage them to use the company’s pacemakers, defibrillators and CRT devices. A Biotronik employee blew the whistle on his employer and will receive about $840,000 in exchange for his notifying the government of the accusation.

To read the complete news release on the situation, visit www.justice.gov/opa/pr/biotronik-inc-pay-49-million-resolve-claims-company-paid-kickbacks-physicians.