Practice Management Alert

Question: There are rumors swirling around the billing office about some Medicare carriers having major issues when switching to the Multi-Carrier System (MCS). Specifically, I-ve heard of downcoding and incorrect denials caused by MCS glitches. Are there really that many problems with MCS?


Washington, D.C., Subscriber

Answer: Issues related to carriers switching over to MCS continue to abound. One of the common fears in billing offices is that the carrier will start downcoding for no discernable reason, leaving the office  red tape in place of justified pay.

However, the problem hasn't so much been downcoding as -completely incorrect adjudication resulting in improper claim denials,- says Holly Louie, compliance officer with Practice Management Inc. in Boise, Idaho.

To make sure the MCS carrier switch isn't affecting your billing practices, Louie recommends that billers watch their explanation of benefits forms from Medicare payers, keeping an eye out for denials that just look wrong.
 
According to Louie, examples of incorrect denials from various carriers have included:

- incorrect recoupments taken on claims previously paid because one carrier's system did not recognize modifier 59 (Distinct procedural service).

- failure to implement the national coverage determination (NCD) for screening mammography with diagnosis code V76.11 (Screening mammogram for high-risk patient) on the implementation date, which has resulted in claim denials.

Overpayments happening, too: -In contrast to not allowing legitimate claims, at least one carrier incorrectly processed all Medicare Secondary Payer (MSP) claims and paid them as the primary payer,-  Louie says. This resulted in overpayments on 100 percent on the claims, she says.

Billers concerned about MCS problems should also watch their carrier Web sites. Some carriers have put up -error resolution reports- on their sites, says Sarah Byers with Family Practice Associates of Lexington, Ky.
 
On the sites, billers can look up each problem and see an estimated date for repair. If that date has passed, you should resubmit any claims affected by that glitch -to waste as little time as possible,- Byers says.

The answers to the Reader Questions were provided and/or reviewed by Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in  Spring Lake, N.J.