Medicare Compliance & Reimbursement

Plus: Feds Charge 35 with genetic testing scheme.

Don’t miss the feds latest ABN change up. While Medicare isn’t revamping its Advance Beneficiary Notice itself, it is proposing a change to the ABN instructions, notes the National Association for Home Care & Hospice.

“Guidelines for Dual Eligible beneficiaries have been added to the ABN form instructions,” Centers for Medicare & Medicaid Services (CMS) says in its Paperwork Reduction Act (PRA) documents supporting the change. “Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” CMS instructs. But you should strike through the language that says “You may ask to be paid now” and “I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.”

Why? “These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” the PRA document explains.

“If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy,” CMS continues. “Medicaid will issue a Remittance Advice based on this determination.”

The instructions then explain that once the claim is adjudicated by both Medicare and Medicaid, providers may charge the patient only when the beneficiary has QMB coverage without full Medicaid coverage, or when the beneficiary with full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid).

Plus: “These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances,” CMS adds.

You can submit comments on this change until Oct. 21. Commenting instructions and a link to the supporting PRA materials are in the rule at  www.govinfo.gov/content/pkg/FR-2019-08-20/pdf/2019-17945.pdf.

In other news…

In another major enforcement takedown, the feds continue to top themselves, protecting the most vulnerable patients from fraud and abuse.

Details: On Sept. 27, the Department of Justice (DOJ) cracked down on genetic testing fraud, charging 35 individuals in cahoots with telemedicine firms and cancer genetic testing labs. Among those charged, nine were physicians.

The fraudsters billed Medicare for more than $2.1 billion for the fake cancer tests. According to the DOJ brief, the defendants lured elderly beneficiaries through telemedicine schemes and also enlisted doctors to scare patients into getting the tests. The feds estimate hundreds of thousands of patients were duped into the testing scenarios.

“The defendants are alleged to have capitalized on the fears of elderly Americans in order to induce them to sign up for unnecessary or non-existent cancer screening tests,” said Ariana Fajardo Orshan, U.S. attorney of the southern district of Florida in a DOJ release. “The genetic testing fraud schemes put personal greed above the preservation of the American healthcare system.”

Find more details on the case at  www.justice.gov/opa/pr/federal-law-enforcement-action-involving-fraudulent-genetic-testing-results-charges-against.