Monthly Archives: April 2016

Hang on to Your Hat and Your Billing Number! Medicare May Revoke Privileges

By: Pam Felkins ColbertThe van Halem Group

2-revokeHang on to your hat and your billing number. It’s gonna be a bumpy ride! As we shared with you back in 2014, the Centers for Medicare and Medicaid Services (CMS) issued a new Final Rule in December 2013 announcing that CMS, under the authority of the Affordable Care Act (ACA), can and will revoke or deny enrollment and billing privileges of providers/suppliers who have a “pattern and practice” of submitting improper claims that do not comply with Medicare regulations and pose a program integrity risk to Medicare.

That Final Rule had become part of federal law and is now included in CMS’ online Program Integrity Manual – Medicare Enrollment, Chapter 15.27.2 (effective 11/02/15), which lists 14 “Revocation Reasons.” Reason #8: Abuse of Billing Privileges is where CMS gives a “hint” of how it determines “pattern and practice” of submitting claims that fail to meet Medicare requirements that may result in your revocation of billing privileges. These factors include:

  1. Percentage of claims submitted that were denied
  2. Reason(s) for claim denials
  3. Provider/Supplier history of final adverse actions and nature of such actions
  4. Length of time over which the pattern has continued
  5. How long the provider/supplier has been enrolled in Medicare
  6. Any other relevant information regarding the provider/supplier specific circumstances that CMS deems relevant

See chapter 15 of the Medicare Program Integrity Manual.

CMS’ Zone Program Integrity Contractors (ZPICs) have also been authorized, as part of its investigations, to recommend revocation of billing privileges. The ZPIC sends its investigation file to the CMS Provider Enrollment Operations Group (now part of CMS’ program integrity functions) to recommend revoking a provider or supplier’s billing privileges. The recommendation may be accepted or sent back for further investigation.

As the ZPIC contracts have come up for re-bid to become Unified Program Integrity Contractors (UPICs), we see much more aggressive investigations and audits, possibly in hopes to support their bids for the UPICs. ZPIC investigations now often include suspension of payments, 100 percent prepay reviews and a closing paragraph, which states:

“Per 42 CFR Section 424.535(a)(8), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges and corresponding provider agreement based on a pattern and practice of submitting claims that fail to meet Medicare requirements. Should you continue to fail to meet these requirements as described above, your billing privileges may be revoked on this basis or any of the bases articulated in 42 CFR Section 424.535(a).“

It is more important than ever to make certain your claims are complete and accurate and have appropriate supporting documentation. If not, you could be deemed as submitting “improper claims that fail to meet Medicare requirements” and “pose a program integrity risk to the Medicare.” If you have been audited in the past, had overpayments taken, educated on the same errors and advised as to why your claims were denied, make certain you DO NOT continue to submit claims with the same errors; this will be scrutinized under the “pattern and practice” elements, and CMS (or its contractors) can and may revoke your billing privileges and corresponding provider agreement.

Be prepared. Be proactive. Prevent audits and overpayments. Protect your billing privileges and provider/supplier agreement.

Are you going to Heartland Conference? If so, attend my session, “How to Navigate the Turbulent Waters of Health Care in 2016.”

Audit Alert – Medicare Payment for PAP Devices

AuditAlertsThe following statement was posted in a recent issue of the CMS MLN Connects Provider eNews:

“The Social Security Act prohibits payment for devices used to deliver continuous and/or bi-level positive airway pressure (PAP) as items requiring frequent and substantial servicing, regardless of the illness the device is being used to treat. These claims will be denied. Using HCPCS codes E0450, E0460, E0461, E0463, E0464, E0465 or E0466 on a Medicare claim for a device used to deliver PAP to a beneficiary is not allowed and could violate the False Claims Act. This is true even if the same device could be used as a ventilator for a different beneficiary.”

A False Claims Act violation can carry penalties that total three times the amount of the claim, plus fines of $5,500 – $11,000 per claim.

Ventilators have been under heavy scrutiny for some time, with suppliers seeing audits from their DME MACs and even the Jurisdiction A RAC. The 2016 OIG Work Plan announced that non-invasive ventilation would also be under their review.

Audit Alert! Suppliers Billing Respiratory Assist Devices (RADs) and Vacuum Erection Devices (VEDs) in RAC Jurisdiction A

AuditAlertsJurisdiction A’s RAC, Performant Recovery, is currently auditing post-pay claims on respiratory assist devices (RADs) and vacuum erection devices (VEDs). States that are affected by this review include Connecticut, District of Columbia, Delaware, Massachusetts, Maryland, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont. The review for both items will be complex, which means the RAC will be asking for medical records on randomly selected claims. Any claims that have a “claim paid date” over three years prior to the ADR date are not subject to this review.

The RAC website described the issue for RADs as, “Potential incorrect billing may have occurred for respiratory assist devices (RAD) that did not meet the medical necessity requirements as described in the NHIC Local Coverage Determinations L33800 and L11504.”

The issue for VEDs was described as, “Vacuum erection devices were paid under the DME Prosthetic benefit, which stipulates the device must be used to replace all or part of an internal body organ. Local Coverage Determinations in effect through June 30, 2015, describe medical necessity criteria. As of July 1, 2015, vacuum erection devises were statutorily excluded from coverage. Potential incorrect billing exists when the documentation does not support the Medicare criteria for coverage.”

In August of 2015, Performant announced that they were conducting complex reviews of ventilators and parenteral nutrition claims.

Audit Alert – Long Descriptions Now Acceptable on the Medicare Proof of Delivery

AuditAlertsMedicare has updated the Program Integrity Manual (Chapter 4, Section 4.26.1) to clarify that long descriptors are valid for the proof of delivery form. Specifically, the manual now reads:

“Suppliers may deliver directly to the beneficiary or the designee. An example of proof of delivery to a beneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1) The patient’s name; 2) The quantity delivered; 3) A detailed description of the item being delivered; 4) The brand name and 5) The serial number. The long description of the HCPCS code, for example, may be used as a means to provide a detailed description of the item being delivered; though suppliers are encouraged to include as much information as necessary to adequately describe the delivered item.”