American Academy of Family Physicians
Wednesday Apr 16, 2014

Medicare releases physician claims data for public consumption

Last week, the Centers for Medicare & Medicaid Services (CMS) released on its website a data set detailing payments made in 2012 to more than 880,000 physicians from the Medicare Part B Fee-for-Service program.

The release of the physician claims data came in response to a legal challenge from the Wall Street Journal, which successfully argued for a federal judge to lift a 1979 injunction preventing CMS from publishing the information. CMS initially planned to evaluate requests for physician payment information on a case-by-case basis. But after receiving numerous requests for the Medicare data, CMS determined the Freedom of Information Act (FOIA) required it to make frequently requested materials available electronically and publicly release certain physician payment information on its website.

This information represents revenue from Medicare Part B services before the practice’s operating costs are deducted. It doesn't include information from Medicare Part A (Hospital Insurance), Part C (Medicare Advantage), Medicaid, Marketplace, or private insurance plans. The data also does not include information associated with clinical diagnostic laboratories or durable medical equipment. Further, this data set does not represent each medical practice’s entire patient panel, and it is not risk-adjusted for severity and complexity of patients treated by the physician. 

The file contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier, Healthcare Common Procedure Coding System code, and place of service.

Physicians and others can access this information by downloading files split by provider last name from the CMS web site. Alternatively, the New York Times and the Wall Street Journal have created tools to search this data by name, specialty, and city/ZIP code.

In future posts, we’ll talk about potential implications of this data release, further limitations of the data, and possible questions you may get from your patients. In the meantime, be aware that the data is out there and that CMS is not the only one looking at it anymore.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Mar 31, 2014

SGR delay puts brakes on Medicare physician fee schedule claims

While physicians wait to see if Congress passes legislation today that avoids a 24 percent cut to Medicare payments, the continuing debate over the Sustainable Growth Rate (SGR) is already affecting claims.

The House of Representatives passed HR 4302 by voice vote on March 27. The bill would delay the SGR's mandated cuts for another 12 months. The Senate was scheduled today to take up the bill, or introduce its own version, ahead of the April 1 SGR deadline.

To give Congress more time, the Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold claims containing services paid under the Medicare physician fee schedule (MPFS) for the first 10 business days of April (i.e., through April 14, 2014). This hold would affect only MPFS claims with dates of service on or after April 1. The hold should have minimal impact on physician cash flow because MACs under current law do not pay clean electronic claims any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MACs will process and pay all claims for services delivered under normal procedures on or before March 31, regardless of any Congressional action – or inaction, as the case may be.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday Dec 23, 2013

A short reprieve from Medicare cuts and a little something extra, too

President Obama is expected to sign into law legislation that would grant physicians a reprieve from drastic cuts in their Medicare payments beginning on Jan. 1. The new law, adopted by the Congress last week, provides a 0.5 percent update to Medicare payments for the first three months of 2014 and avoids a 24 percent cut otherwise required under current law.

That action gives Congress three more months to complete its work on legislation that would repeal the Sustainable Growth Rate (SGR) without further disruption to the Medicare program. Both the Senate Finance Committee and the House Ways and Means Committee (amending a bill produced by the House Energy and Commerce Committee) have overwhelmingly approved similar but not identical bills – the SGR Repeal and Medicare Beneficiary Access Act (S 1871) and the Medicare Patient Access and Quality Improvement Act (HR 2810). The three-month extension of the Medicare physician fee schedule (with a 0.5-percent increase) means that the two committees have until March 31 to work out the differences in the bills.

In the meantime, physicians must make decisions about their Medicare participation status for 2014. Physicians wishing to change their Medicare participation or non-participation status for 2014 are required to do so by Jan. 31, 2014. Participation decisions are effective Jan. 1, 2014, even if made between then and Jan. 31, 2014, and are binding for the entire year. More information on physicians’ Medicare participation options is available on the AAFP web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday Oct 01, 2013

Medicare payments unaffected by government shutdown ... for now

Tuesday’s partial shutdown of the federal government may have you wondering if your Medicare payments will be delayed. The short answer is, “not immediately.”

According to a Department of Health and Human Services contingency plan, “In the short term, the Medicare Program will continue largely without disruption during a lapse in appropriations.” The Centers for Medicare & Medicaid Services has also reassured providers by email, “During the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payment.”

So, for now, Medicare payments will continue to flow to physicians even as other parts of the federal government grind to a halt.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Mar 14, 2013

The biggest driver of health care spending

Earlier this month, the National Commission on Physician Payment Reform released a report that listed the four factors it singled out as the biggest drivers of high health care system spending.

Topping the list was fee-for-service reimbursement. The commission recommended that payers should largely eliminate stand-alone fee-for-service payments to medical practices over the next five years, blaming the scheme's inherent inefficiencies and negative incentives toward more care. Instead, the commission advocated "an approach based on quality and value" and "fixed-payment models."

Does this mean that the commission expects fee-for-service to disappear in five years? Not necessarily. In fact, the commission said it expects that "fee-for-service will remain an important mode of payment into the future," which is why it also has recommendations on how to "recalibrate" it in the interim.

The commission's report adds to the chorus of those advocating for a reduced role for fee-for-service in the future of physician payment. Medicare is moving toward value-based payment and experimenting with blended payment approaches in approaches in its Comprehensive Primary Care Initiative. Other payers are doing the same. While there is no suggestion that we will ever completely cure ourselves of fee-for-service, there is every indication that it is a treatable condition whose adverse effects, especially on primary care physicians’ quality of life, can be reduced.

(In case you were wondering, the next three practices the commission said are contributing to high spending were a reliance on technology and expensive care, reliance on a high proportion of specialists, and insurers paying hospitals more for certain services or procedures than they would in an outpatient setting.)

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Jan 17, 2013

Avoiding Medicare cliff still has initial consequences for payment

With the Medicare payment cliff averted for now, Medicare and its contractors are beginning to implement payments for 2013 services. Here is what you can expect, based on information provided by the Centers for Medicare and Medicaid Services (CMS).

First, CMS is revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law's requirements as well as technical corrections identified since publication of the final rule on the 2013 MPFS in November 2012. Officially, the 2013 conversion factor is $34.0230.

Second, to allow sufficient time to develop, test, and implement the revised MPFS, Medicare contractors were able to hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through Jan. 15). CMS expected those claims to be released into processing no later than Jan. 16. The claim hold should have minimal impact on your cash flow, however, because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt anyway. Claims with dates of service prior to Jan. 1, 2013, are unaffected.

Medicare contractors will be posting the correct MPFS payment rates on their websites no later than Jan. 23. If you have downloaded or will be downloading the fee schedule from your local Medicare contractor's web site, double-check to ensure that it reflects the correct rates, based on the recent change in the law.

Finally, the 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their Medicare participation status by Dec. 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through Feb. 15, 2013. Therefore, you have until Feb. 15, 2013, to postmark any participation changes (both elections and withdrawals) that you want to make. The effective date for any participation status changes during the extension remains Jan. 1, 2013, and will be binding for the rest of the year.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Dec 06, 2012

Rethinking your Medicare participation options?

With just a little more than three weeks left before the wheels could fall off Medicare payments, you may be rethinking your level of involvement with the program.

Congress may step in again this year to avoid the scheduled 26.5 percent cut tied to the Sustainable Growth Rate formula. But if not, here is a brief look at the options open to you and ways to reduce your Medicare exposure, even if you remain a participating physician.

You have three Medicare contractual options. You can sign a participating (PAR) agreement, accepting Medicare's allowed charge as payment in full; elect to be a non-PAR physician, which allows you to take Medicare patients on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims; or opt out and become a private contracting physician who bills Medicare-eligible patients directly for your services.

You have until Dec. 31 to change your Medicare participation or non-participation status for 2013. Before making a change in status, you should first determine that you are not bound by any contractual arrangements with hospitals, health plans, or other entities that require you to be a PAR physician.

Even if you choose to continue being a PAR physician, there are ways that you can limit your Medicare exposure. For instance, you can refuse to treat Medicare patients except on an emergency basis. Medicare is a voluntary program, and nothing requires you to treat Medicare patients in your practice if you do not wish to do so. You can also limit your practice to existing Medicare patients only and accept no new Medicare patients. Lastly, you can reduce the number of Medicare patients in your practice.

For more information, see Family Practice Management's previously published articles on opting out of Medicare and preparing for a Medicare fee cut.  

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians 

Friday Nov 30, 2012

Medicare releases its final rule on the 2013 physician fee schedule

On November 16, the Centers for Medicare and Medicaid Services (CMS) published the final rule on the 2013 Medicare Physician Fee Schedule, changing the physician fee schedule and other Medicare Part B payment policies and implementing certain provisions of the Affordable Care Act.

The regulation also discusses:

Among the highlights in the final rule:

  • In 2013, CMS will pay for new Current Procedural Terminology transitional care management codes, 99495 and 99496, with some small modifications. Based on the relative value units that CMS finalized and assuming that Congress averts the pending 26.5-percent reduction discussed below, code 99495 performed in a facility will pay approximately $135; in a non-facility setting, 99495 will pay approximately $164. Code 99496 performed in a non-facility will pay approximately $231.12, and when performed in a facility setting, it will pay approximately $197.76.

  • CMS delayed to July 1, 2013, the effective date of its requirement that a face-to-face visit be a condition of payment for certain high-cost durable medical equipment (DME) covered items. The list included many items that have historically been targets of Medicare fraud as identified by various program integrity experts. The encounter must occur within six months before the written order for the DME. CMS is not mandating additional documentation beyond what the physician or other qualified health professional would normally document during the actual face-to-face encounter.

  • CMS is limiting the applicability of the value-based payment modifier to groups of 100 or more eligible professionals during 2015, the first year it will be effective. This means that most family physicians will not have to worry about it for now.

CMS estimates that, all things being equal, family physicians will experience a 7-percent increase in their Medicare allowed charges in 2013 as a result of what is in the final rule.

Unfortunately, that assumes no change in the Medicare conversion factor from 2012. However, as noted in the final rule, the conversion factor under current law will decrease 26.5 percent to approximately $25 (from the current $34.04), effective with dates of service on or after Jan. 1, 2013. That means, unless Congress intervenes in the interim, the drop in the conversion factor will more than wipe out the projected 7-percent increase.

So, there is good news and bad news in the final rule this year. Only time will tell which will prevail, so stay tuned. In the meantime, for more information on the final rule, please visit the American Academy of Family Physicians' web site.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians 

Friday Nov 02, 2012

'Tis the season...influenza season, that is

The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.

CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.

The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:



Payment allowance


Influenza virus vaccine, split virus, preservative free, when administered to children 6 to 35 months of age, for intramuscular use



Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use



Influenza virus vaccine, split virus, when administered to children 6 to 35 months of age, for intramuscular use



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular (Afluria)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)



Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)


Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:

•    90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
•    90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
•    90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.

The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.

In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.

For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday Jan 26, 2012

New HCPCS codes worth noting

The Centers for Medicare & Medicaid Services (CMS) has released a quarterly update providing new Healthcare Common Procedure Coding System (HCPCS) codes for January 2012. Often the HCPCS updates don't have much to offer family physicians, but this group may be worth noting.

You have probably seen the announcements of new Medicare coverage for preventive services such as intensive behavioral therapy for cardiovascular disease risk and obesity, screening for depression, and screening for sexually transmitted infections. What is missing for some of these newly covered services is the guidance on what must be included and documented for the services, the codes used to report them, and the payment amounts for each. AAFP staff have put together a table of what we know so far about the codes, who can provide the services and in what settings, and how often each service is covered. There is still a lot we do not know, including when these services will be bundled with other services provided on the same date, but CMS should soon publish that information in the April 2012 National Correct Coding Edits.

Other notable 2012 HCPCS codes include the following:

G0449: Annual face-to-face obesity screening, 15 minutes – notable because this new code is listed in the fee schedule as a non-covered service,

G0451: Development testing, with interpretation and report per standardized instrument form – notable because this may be required by Medicaid or health plans in lieu of CPT 96110 due to the change in the CPT code descriptor to "Developmental screening, with interpretation and report, per standardized instrument form,"

G9156: Evaluation for wheelchair requiring face-to-face visit with physician – notable because this code is used to report services related to a CMS action to correct improper payments for power mobility devices. Medicare contractors in the following states, CA, FL, IL, MI, NY, NC, and TX, began 100 percent prepayment review for initial rental or purchase claims after Jan. 1, 2012 and prior authorization of power mobility devices beginning April 1, 2012. This may be implemented in other states in the future. To compensate physicians for time associated with preparing and submitting a prior authorization request, code G9156 is reported after submission of the initial prior authorization request with the prior authorization tracking number provided by the Medicare durable medical equipment contractor. Claims are submitted to the Medicare Part B contractor and only one claim with code G9156 may be billed per beneficiary per power mobility device even if a physician must resubmit the request for prior authorization. For more information from CMS, see this presentation.

There will likely be more changes to come in 2012, especially to the preventive service benefits as defined by the Affordable Care Act. Here's hoping the benefits to patients outweigh the complexity of the Medicare benefit structure!

Friday Nov 11, 2011

What the 2012 Medicare Physician Fee Schedule tells us about the future

The final rule for the 2012 Medicare Physician Fee Schedule went on display this week. Of course it includes the all-too-familiar fee cut (27.4 percent) – the result of the Centers for Medicare & Medicaid Services' (CMS) flawed formula for calculating physician payment that Congress has been patching annually since 2002 but which needs a permanent fix. This year's fee schedule is notable for another reason as well. The PDF file is 1,235 pages long, and that's without the appendices that will be included when the final rule is published in the Federal Register later this month. The fact that it requires so many pages to describe one year's changes to one part of one government program is mind-boggling, but the additional bulk is partly because this year the rule also provides a forecast for how CMS plans to carry out government mandates for the program over the next five to 10 years. It is not a crystal ball, but the rule leaves no doubt that Medicare payment to physicians will be changing and that today's initiatives and incentives are intended as the basis for tomorrow's payment.

Examples of this are especially clear in the portion of the rule that speaks about a value-based payment modifier, which will actually modify payments under the Medicare Physician Fee Schedule based on Medicare's record of the quality of care you provide to patients compared with the cost of that care. Where will Medicare get this data? Primarily from the quality measures reported for programs like the Physician Quality Reporting System and the EHR Incentive Program and from claims data for your patients. Physicians who are found to deliver high quality for the cost of care will be paid more than other physicians. The program is budget neutral, so one physician's gain is another physician's loss.

CMS is still working out the details, such as how to attribute patients to physicians, adjust for risk and complexity, and make the measurements meaningful for all specialties. What is clear from the rule is that the process is underway to put the value-based modifier in place by 2015 for some physicians (based on claims and quality reporting in 2013) and by 2017 for all physicians (probably based on claims and quality reporting in 2015).

 CMS has this to say in the final rule:

"We strongly encourage physicians to participate in the Physician Quality Reporting System program and the EHR Incentive Program sooner rather than later and to choose to report quality of care measures that best reflect their practice and patient population. Although we have not yet proposed the value modifier methodology, our primary interest at this point is to increase the quality of care for Medicare beneficiaries. We note that we also plan to propose a value modifier in rule making during 2012, prior to the initial performance period. Thus, we believe it is reasonable to encourage physicians to report appropriate quality measures well in advance and irrespective of the exact value modifier methodology at this time."

The complexity and unknowns of this value based payment system are daunting.  However, this could be a good thing if physicians who know their patients and provide comprehensive, coordinated care are rewarded for their work. Sounds like family medicine to me.

Monday Jan 31, 2011

Like a shot in the arm – or not

Jan. 1, 2011 brought quite a few changes to primary care. Some are good. Others that should be good are overly complex (if you have looked at the Medicare annual wellness visit requirements, you know what I mean) or lack acceptance among payers, which is the problem with the new pediatric vaccine administration codes, the subject of this post.

The new pediatric vaccine administration codes were developed to recognize the physician work of counseling patients about each component of combination vaccines. I provided details about these codes in a previous blog. I have heard from some practices that they have seen increased payment for the vaccine administrations from some payers. Unfortunately, other payers are not yet on board with the need to make provision of childhood vaccines an affordable endeavor.

Here is some disappointing but important guidance from the CDC regarding Vaccines for Children (VFC) payment:

In the VFC program, the regional vaccine administration fee cap rates were established on a per-vaccine basis, not on a per-antigen or per-component basis. Under current interpretation of CMS policy, the administration fee for the VFC program will continue to be based on a per-vaccine basis and not on a per-antigen or per-component basis. CMS is looking closely at the VFC administration fee cap to ensure that it keeps up to date with changes in underlying costs of providing vaccines and with medical practice. CMS anticipates updating the fee cap in the near future, and is also examining the larger reimbursement structure of the VFC program. In the meantime, state Medicaid agencies can increase the amount they pay providers up to their regional cap by submitting a State Plan Amendment, as most states are currently paying providers rates that are below their state caps. In addition, a state could choose to establish different rates, up to their regional cap, for a vaccine with multiple antigens and those that are single components.

VFC-enrolled providers may not charge a vaccine administration fee to VFC-entitled children that exceeds the regional administration fee cap per dose of vaccine.

Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program. If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-Medicaid-enrolled VFC-entitled children (i.e., uninsured, underinsured, and American Indian or Alaska Native children not enrolled in Medicaid).

Also, here's what you need to know about private payers' handling of these claims: Make sure that the person who reviews your payments watches for the number of units allowed by payers. Some are substantially limiting the payment for code 90461. For some this is a system error that is to be corrected, but not for all. One payer's policy blatantly states that it will pay for only one unit per date of service for the primary vaccine administration, 90460, and only 3 units for "additional injections" using code 90461. In other words, the payer is ignoring the per-component-oriented descriptors in CPT 2011. The payer goes on to say, "Maintaining the 'per administration/injection' definition from the 2010 immunization administration codes (90465/90466, 90471/90472) will allow a budget-neutral conversion. The 2011 allowances will reflect a 1% increase." Apparently this payer has never heard that HIPAA prohibits changing the code descriptors. I wonder if the payer's premiums and profits are "budget neutral."

But I didn't write this to depress you. Be aware that the AAFP (and the American Academy of Pediatrics, which has invested extensive time and effort in acceptance and payment of the new codes) is advocating for fair and correct payment of these codes. And as mentioned previously, some payers did begin paying the codes as intended on Jan. 1. We will keep working on the rest.

Thursday Oct 22, 2009

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

Friday Sep 25, 2009

Records requests: Answer carefully

Your practice probably receives multiple requests for records each week. Unfortunately, more and more of these requests are related to your claims for payment. With ever-growing reports of waste and abuse in health care and profits to be made in recovering money paid to physicians and other providers, these requests are not going away. Whether from Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) program contractors, private payers or Medicaid plans, how your practice responds to these requests can make a big difference in your practice's financial future.

So the first question is, who responds to these requests in your practice? Do they understand the importance of sending the right records to support the services billed and doing this in the time period specified on the request? Many of you may be familiar with the CERT program that the Centers for Medicare & Medicaid Services (CMS) commissioned to review the accuracy of claims paid by their Medicare contractors. Some of the most common reasons for errors in the program are these:

  1. Records not sent.
  2. Records sent but not for dates or services billed.
  3. Records illegible or unsigned.

If your practice doesn't provide the records to substantiate your charges, the claim is found to have been paid in error. Medicare contractors are obligated to recover money paid in error. Auditors working for private payers are incentivized to recover money paid in error.

The second question is whether you have a process for making sure that all documentation is provided to support the charges in question. If not, it is probably time to implement one. Here are some tips that might help:

  • Identify a primary and back-up staff person to receive all records requests related to claims or payment.
  • Create a log identifying the date the request was received, the type of records requested and the date the records were sent.
  • If there is any question whether documents are legible or sufficient to support the services that were billed, the physician or other provider of services should review the records and provide a transcribed copy of the documentation in addition to a copy of the original documentation and/or a letter explaining any additional information that may have bearing on the outcome of the review. (Any addendum to the original documentation should be signed with the current date added.)
  • Create a checklist to be used in confirming that copies are ready to be mailed.

Establishing a formal process for responding to requests for records may provide a framework for ensuring that all are appropriately and efficiently handled and help to identify recurring gaps in documentation. It may also protect money already paid to you as well money that you are due.

There are already too many opportunities for practices to lose money in the insurance billing process. Most practices can't afford to take lightly efforts by Medicare and others to recover money they have already been paid.

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