Medicare Compliance & Reimbursement

Between the IPPE, AWV, AAA, and beyond, you're probably confused at the alphabet soup of options when billing preventive services to Medicare. CMS feels your pain, and has released a quick reference chart that can ease your billing woes when you provide preventive care to Medicare patients.

Likewise, if your patient presents for a quantitative blood glucose test to screen for diabetes, the chart indicates that you'll report 82947 with diagnosis code V77.1, and you should not charge the patient coinsurance or deductible. Medicare covers this visit twice a year for pre-diabetic patients and once a year for patients with certain diabetes risk factors.

To access the chart, visit the CMS Web site at www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf.

Are you referring a vast number of patients to the same rehab facility every time? The OIG may want to talk to you.

Nine healthcare professionals, including four physicians and one physician's assistant, were charged last week with conspiracy to violate the Anti-Kickback Statute after they were accused of accepting cash for referrals to a Michigan-based group of medical clinics, rehab facilities, and home health companies.

The owner of the facilities is alleged to have paid the healthcare providers for referring patients for electro-diagnostic testing, physical therapy, and home healthcare services. The rehab provider disguised the kickbacks as reimbursement for non-existent expenses, such as mileage, continuing medical education, and medical director fees, according to a Jan. 24 Department of Justice press release.

The healthcare workers face up to five years in prison and a $250,000 fine. To read the government's press release about the case, visit www.fbi.gov/detroit/press-releases/2012/nine-health-care-professionals-including-five-doctors-charged-in-kickback-scheme.

Medicaid overpayments could get you in trouble this year. Are you hanging on to a Medicaid overpayment and maintaining it as a credit balance? The OIG may want to chat with you in 2012.

When you receive an overpayment from Medicaid, you are expected to send it back -- the amount of time you can spend before you refund the money varies from state to state, but if you are aware of an overpayment, you must pay it back. And the OIG is looking for practices that haven't been holding up their end of that deal.

"We will review patient accounts of providers to determine whether there are Medicaid overpayments in the accounts with credit balances," the Work Plan indicates. "Previous OIG work found Medicaid overpayments in patients' accounts with credit balances. Medicaid is the payer of last resort and providers are able to identify and refund overpayments received."

Translation: All other available payers "must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid," CMS says in its "Third Party Liability Overview." Therefore, if you erroneously bill Medicaid first, and then another payer reimburses you for what Medicaid has already paid you, you must repay Medicaid that amount.

The OIG 2012 Work Plan is online at http://go.usa.gov/93X.

"In the light of the fact that SNFs receive a significant part of Medicaid funds as opposed to Medicare funds, it is expected that the percentage of nursing facilities audited by Medicaid auditors will be substantial," warns attorney Wayne Miller, with The Compliance Law Group in Thousand Oaks, Calif.

Attorney Paula Sanders thinks one area of vulnerability for nursing homes will occur in states that allow facilities to bill a hospital reserve day(s) when Medicaid patients are hospitalized. "If the facility bills improperly or its system doesn't pick up timely that someone returned from the hospital, that's an easy automated piece for the RACs" to detect, advises Sanders, with Post & Schell in Harrisburg, Pa.

Also: "Even though they say there won't be overlap between the MICs [Medicaid Integrity Contractors] and Medicaid RACs, I don't know how that can be [as] they are looking at the same thing," adds Sanders. "In my mind, it's difficult to separate the MICs from the Medicaid RACs unless you say the MICs will look more for 'integrity issues' while the Medicaid RACs will focus more on abuse and waste as opposed to fraud."