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Medicare Compliance & Reimbursement

Reimbursement:

Don't Bill Unless Patient Info Is Correct - And Complete

Published on Wed Jan 26, 2005

Some carriers are asking for middle initials, other data

Frequently, physicians may perform services for patients without seeing them face-to-face. In those cases, obtaining the exact information on those patients' Medicare cards is doubly important, experts say.

In cases when a physician interprets electrocardiogram readings or receives lab specimens, the physician may rely on the information he or she receives from the referral source to bill Medicare. But now, more than ever, the slightest error in that information can lead to weeks of delays for the physician's claims.

The reason: The Centers for Medicare & Medicaid Services has tightened requirements, officials said in the latest Physician Open Door Forum (ODF) Jan. 12. CMS used to require only that three out of five "beneficiary-identification elements" should be accurate on a claim. In some cases, Medicare would pay claims even if the patient's name was misspelled or the patient's Medicare number was incorrect.

But the HHS Office of Inspector General objected to these loose requirements and demanded that CMS switch to an all-or-nothing standard. Now, CMS has switched to requiring that three out of three data elements must be correct - the beneficiary's last name, HIC number and first initial.

"We understand that as a result of this policy those providers that are dependent upon other providers sharing beneficiary-specific information with them" may have a problem with the accuracy of the information, a CMS official said.

The good news: Medicare doesn't deny these incorrect claims. Rather, the claims are rejected, meaning there's not an extensive appeals process to correct the claim. Some carriers may allow providers to call in with the correct information, and others may simply allow providers to resubmit the claim.

A provider often will receive a referral from a hospital or a nursing home for a patient with Alzheimer's disease who's incapable of correcting her own information, one provider said during the ODF. If the hospital or nursing home passes along incorrect information, the physician can't get paid. And even with every other correct piece of information, the physician can't obtain the last bit of correct data from the carrier.

For example, if the patient typically goes by her middle name, the chart may not list the patient's actual first name, the provider noted. The hospital or nursing home also may not be able to bill with that incomplete information, but it may take an institutional provider much longer to come to grips with the problem, the physician complained.

Another problem: In some cases, carriers are demanding more than a patient's last name and first initial, said Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ. She told the ODF that one carrier is demanding the patient's name exactly as it appears on the Medicare card, possibly including a middle initial. When a physician receives a referral from a hospital and doesn't see the patient's Medicare card, the coder won't necessarily have that full name available.

And other coding experts pointed to recent carrier bulletins stating that carriers will require a patient's full first name and middle initial on claims. CMS officials said they'd look into this issue further.

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