Medicare Compliance & Reimbursement

Hint: Know the interest accrual rules on overpayments.

As your practice updates its coding and billing protocols for 2020, it’s a great time to review Medicare’s rules. Ask yourself these five questions and review the answers to keep your reimbursement in line next year.

1: Understand Unprocessable Claims

Question: Your claim is rejected and you receive an MA130 denial message. What does that mean?

Answer: “Your claim was rejected because it contained invalid or incomplete information,” says Gail O’Leary, a provider outreach and education consultant with Part B MAC NGS Medicare in the webinar “Top Reasons for Appeals.”

According to the Centers for Medicare & Medicaid Services (CMS), this is best described as unprocessable and refers to any claim with incomplete, missing, or invalid required information, suggests the Medicare Claims Processing Manual. There are several reasons a claim may be returned unprocessed, including things as varied as an invalid modifier, wrong procedure, or an incorrect Medicare Beneficiary Identifier (MBI).

Find more details and review other reasons claims are returned “unprocessable” at  www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf.

Tip: Remember, “you don’t have any appeal rights on this type of denial because your claim was never processed in our system,” O’Leary reminds. “Your only recourse is to correct your error and resubmit for processing.”

2: Know the Facts on Reopenings

Question: Your claim is denied for a minor error. What is an option you have to fix the issue?

Answer: If you submit a claim and get a rejection due to a simple clerical error, you might be able to “reopen” the claim to fix your error rather than filing an appeal.

“Reopening is a process for correcting a minor error or omission on a claim without having to pursue the formal appeals process,” advises O’Leary.

You can request a reopening online, by phone, or by written request once the claim has been finalized. During reopening, you can change items such as the charge, the place of service, the quantity billed, the date of service (as long as it’s in the same calendar year), the procedure or diagnosis code, or a patient’s Medicare number.

Limitations: You can’t use reopening to change the year on a date of service or to change billing provider information. Nor can you use reopening to add a line of service not billed on the initial claim, or for any change that requires additional documentation for a redetermination.

3. Use the Correct Modifier to Sidestep Duplicate Submissions

Question: A patient comes into the office for tennis elbow and receives an x-ray. The radiologist sees something unusual in the x-ray and needs a second opinion. What modifier do you append to CPT^® code 73070 (Radiologic examination, elbow; 2 views) for the second x-ray and other physician’s interpretation?

Answer: You append modifier 77 (Repeat procedure by another physician or other qualified health care professional). Modifiers are especially important to avoid duplicate submissions because the appended modifier shows that though you are performing the same service, it is separate, and therefore, not the same for a reason.

In this case, the physician’s notes would verify that the second x-ray, and another physician’s interpretation, were necessary.

4. Review What ‘Direct Supervision’ Means in the Incident-To Guidelines

Question: Is it true that if there is no ‘direct supervision’ by a physician, the nonphysician practitioner (NPP) cannot bill incident-to?

Answer: “True,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “If you have more than one physician in your practice and neither is in the office suite when the services are rendered, you would also be correct that the claim would need to be billed under the NPP’s NPI [National Provider Identifier], if the NPP is credentialed by the payer.”

Reminder: “Direct supervision in the office setting means that the physician is in the office suite,” Falbo counsels. “The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

Of note: “Keep in mind that incident-to guidelines were developed by Medicare, and other insurance carriers do not necessarily follow Medicare’s lead,” explains Falbo. “It is important to check with the third-party payers to ascertain if they follow Medicare’s incident-to guidelines ... or obtain clear guidelines as to their requirements.”

5. Respond to Overpayments Quickly

Question: Is there a procedure for returning overpayments to Medicare?

Answer: Yes. CMS stipulates a 60-day limit on returning overpayments to federal agencies. The rule might seem simple, but you’ll want to ensure you comply since compliance failure could lead to huge penalties.

The reasoning: Every practice occasionally handles overpayments, but the 60-day rule is designed to help practices identify systemic overpayment problems. Federal officials expect providers to keep close enough tabs on payments to find any coding or billing issues early so they can be dealt with in a timely fashion. Any overpayments you discover should then be refunded to CMS within the 60-day window, and the underlying problem fixed to avoid future overpayments.

Tip: Remember that the clock starts ticking on the date the issue is discovered, not the date of service or payment.

Dealing with any overpayments quickly is important because if federal agencies discover that you knew about overpayments and failed to repay them promptly, you could be looking at penalties related to the False Claims Act (FCA) or the Civil Monetary Penalties Law (CMPL).

In the worst-case scenario, your organization could be excluded from all federal healthcare programs. 

Interest: Even if you get to the redetermination or reconsideration points in your appeal — levels 2 and 3 respectively — “interest will continue to accrue on the overpayment if not repaid within 30 days of the original demand date,” notes Part B MAC Novitas Solutions in an appeals FAQ. Plus, “if not repaid, interest will continue to accrue for each subsequent full 30-day period.”

And even “if there is a reduction in the overpayment amount, interest will recalculate and adjust for the overpayment amount from the original demand date, regardless of the date the revised overpayment amount is determined,” Novitas adds.

Bottomline: “A valid appeal request (redetermination or reconsideration) will delay offset (unless otherwise requested) but will NOT cease the assessment of interest,” warns the Part B MAC.