Medicare Compliance & Reimbursement

Question: Our primary care practice has seen an uptick in denials of our Part B claims. Is it worthwhile to request a Comparative Billing Report (CBR) from our Medicare Administrative Contractor (MAC) and contrast our billing practices against other local providers?

Indiana Subscriber

Answer: Yes, benchmarking is an incredibly useful tool and can offer insight into your billing problems. Not only can CBRs help your practice identify outlier behavior, but the data garnered from the reports can enhance your compliance planning.

“The Comparative Billing Report (CBR) for Part B providers furnishes a detailed examination of the comparative data that Medicare considers when determining how the provider’s billing patterns contrast with those of other providers of the same specialty,” reminds Part B MAC First Coast Service Options, Inc. (FCSO) in online guidance.

Part B MAC CGS guidance adds that CBRs offer providers “specific billing pattern data in comparison to peer groups within the state” where they practice.

For example: When your MAC reviews E/M coding percentages — which show the range of codes billed from low-level to high-level — it is scrutinizing the curves that are heavily weighted to the high side and seeing whether a practice was overpaid. However, many Medicare carriers also look at those providers that err on the low side of the curve, too, because that billing behavior is an indicator that incorrect coding might be occurring.

Tip: Additionally, you may want to keep an eye on the CBRs that your Part B MAC releases to see where your statistics fall. Most Medicare contractors post these on their websites in an effort to educate the provider community about the averages.

You can request a personalized CBR specific to your Provider Transaction Access Number (PTAN) and/or National Provider Identifier (NPI) based on the date of service and the HCPCS or CPT^® code you plug in. The MACs usually accept these requests through their jurisdiction-specific web portals, so check with your Medicare carrier on the particulars.