Medicare Compliance & Reimbursement

Plus: Suppliers must go beyond CMN, court says. The Part B carriers are putting in place edits designed to make sure doctors don't bill the technical component (TC) of an inpatient radiology service that a hospital is already billing for separately, according to Transmittal 1098 from the Centers for Medicare & Medicaid Services (CMS), dated Nov. 2.
 
Double radiology billings are a hot-button issue since the HHS Office of Inspector General (OIG) zeroed in on them in a recent report, exports note. Current Medicare policy allows either the hospital or the supplier providing the TC of radiology services to bill for the services, and this has led to Medicare paying twice for the same services.

The edits will take effect by April 1, 2007. Carriers will deny the TC or globally bundled radiology and pathology services that the hospital should be billing for, according to CMS. Providers can appeal denials under this edit, and the carrier has the ability to override it in some cases. HHS Can Use A Higher Reimbursement Standard For Suppliers Suppliers of durable medical equipment, prosthetics, orthotics and supplies may have to submit additional evidence beyond a certificate of medical necessity (CMN) to show the equipment is medically reasonable and necessary, according to a new decision by the U.S. Court of Appeals for the Eleventh Circuit. The decision, announced Nov. 3, allows the U.S. Department of Health and Human Services (HHS) to hold suppliers to a higher standard to secure payment from Medicare Part B. In the case, Gulfcoast Medical Supply Inc. v. HHS, the court concluded that the Medicare Act "unambiguously permits Medicare Part B carriers and the HHS secretary to require suppliers to submit evidence of medical necessity beyond a CMN."

The appeals court rejected the argument by Gulfcoast Medical Supply Inc., a Florida-based supplier of durable medical equipment, that the HHS secretary has no discretion to request additional medical necessity documentation beyond a CMN. "If, as Gulfcoast suggests, the carriers and the Secretary have no discretion to request any evidence of medical necessity apart from the CMNs already submitted by the suppliers, such audits would be rendered useless, the per curiam opinion said.

"Moreover, were we to adopt Gulfcoast's position, the Secretary would effectively lack the discretion to deny any claim so long as a supplier could find a physician -- even a dishonest or incompetent one -- to sign a CMN."

The court's decision is available at www.ca11.uscourts.gov/opinions/ops/200516935.pdf.