Provider Self-Disclosures of Overpayments for Medicare Part C – Managed Care

medicare part c overpayment

medicare part c overpaymentBy: Karina Gonzalez

When providers or suppliers self-report overpayments to Medicare Part C Managed Care organization, there is some uncertainty on what lookback period applies and whether there actually is an overpayment obligation. Is it Medicare’s 60-day overpayment rule that applies or do the Managed Care Part C organizations impose a different lookback period for overpayments?

CMS (The Centers for Medicare & Medicaid Services) published its Final Rule clarifying the procedures applicable to the statutory requirement under the Affordable Care Act (“ACA”) for providers and suppliers to self-report and return overpayments. (The Final Rule was published on February 12, 2016). The Final Rule applies to Medicare Parts A and B and addresses the procedures that a provider or supplier need to follow to investigate, identify, quantify to self-report and return an overpayment. The Final Rule clarifies the obligations of Medicare providers and suppliers to report and return overpayments for claims originating only under Medicare Parts A and B. The final rule does not address, or reference, the obligations of providers to return overpayments to Medicare Advantage organizations for Part C claims.Continue reading

CMS Releases New mHealth Codes for 2019

mHealth codes 2019 CMSBy: Amanda Bhikhari

Improving patient outcomes while maintaining physician decision making and practice efficiency is key to success in the growing health care arena. Innovation is the ability to see change as an opportunity to create new value, instead of a threat to what we find comfortable. It is clear that the Center for Medicare and Medicaid Services (CMS) is embracing the importance of innovation in the way we deliver health care.

In November 2018, the 2019 Physician Fee Schedule and Quality Payment Program was released by CMS with changes effective January 1, 2019.  This is the time for providers to definitely keep their eyes open to utilizing mHealth, and telehealth services. mHealth is also known as mobile health, and is a general term for the use of mobile phones and other wireless technology in medical care to educate consumers about preventive healthcare services as well as for disease surveillance, chronic disease management, treatment support, epidemic outbreak tracking. The release of the program is a sign that the agency is in favor of expanding the implementation of technology in providing medical care.  The updated mHealth codes are:Continue reading

Medicare Opt Out: Part II

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medicare opt outBy: Susan St. John

As noted in Opting Out of Medicare Part I, opting out of Medicare may be an option for some physicians and practitioners. After determining whether you are eligible for opt-out or if it is financially feasible, there are a few other considerations. Part I discussed the Private Contract a physician must enter into with each Medicare beneficiary he or she treats; here, we will address the opt-out affidavit and other nuances of opting out. Let’s get started!

The Medicare Opt Out Affidavit

Provisions in an Opt Out Affidavit are similar to provisions that must be included in the opted out physician’s or practitioner’s private contract with Medicare beneficiaries. The opt-out affidavit must state that the physician or practitioner will only provide services to Medicare beneficiaries with whom they have a written and signed private contract and that the physician or practitioner will not submit claims to Medicare on behalf of Medicare beneficiaries. Medicare does allow for an exception here, but that is only when an opted out physician or practitioner treats a Medicare beneficiary who is not under private contract, and that beneficiary presents with a medical emergency or urgent care problem. Keep in mind, that if a Medicare beneficiary presents with a medical emergency or urgent care problem, the physician or practitioner cannot require that patient to sign a private contract at that time.Continue reading

Trend Watch: Usual and Customary Rate on the Decline

By: Karina Gonzalez

Most of the commercial payors are paying PHP (Partial Hospitalization Plan) and IOP (Intensive Treatment Plan) at a bundled daily rate. Many of the plans are now adding urine drug screens to the bundled daily rate and imposing a cap on the number of screens that can be done during an admission.  Plans are paying rates that are much nearer to a Medicare rates.  Payments based on a reasonable percentage of a provider’s charge are becoming harder to find, as the calculation of what is a usual and customary rate of payment continues to decline.

Yet, a great portion of substance abuse facilities are operating with more clinical staff, at a higher level through licensure, with better Electronic Medical Systems, more programs to combat some of the symptoms of addiction and with a greater awareness of compliance with state and federal guidelines.  Even with these necessary improvements, reimbursements continue to decline.Continue reading

The United States Supreme Court adopted an “Implied Certification Theory” in “some circumstances”

bcbs lawsuitBy: Karina Gonzalez

The Supreme Court of the United States in the case of Universal Health Services v. United States ex rel. Escobar (decided 6/16/2016) extended the reach of the False Claims Act (FCA) to cover implied false certifications made “in certain circumstances” by healthcare providers in requesting payment for goods and services.

At issue was a theory of liability known as the “implied false certification theory” and whether this theory was valid under the FCA.  The implied false certification theory treats a payment request as an implied certification of compliance with relevant statutes, regulations or contract requirements that are a material condition of payment and treats a failure to disclose a violation as a misrepresentation that renders the claim false or fraudulent. Continue reading