Special Bulletin: CUA Working For You

Updates From California Medicare Carrier | Avoiding Medicare Claim Denials

Updates From California Medicare Carrier

Jeffrey Kaufman, MD, FACS
CUA Representative
Medicare Carrier Advisory Committee

You may be aware that formal audits are increasing from both public and private payers. A recent random survey by the CERT contractor for Medicare identified an alarming number of errors that will result in denied reimbursement as well as false reports to Congress that inflate their view of how physicians are delivering care to Medicare recipients. Most of these "errors" are little more than minor "gotcha's"-that is, the care was indicated and properly delivered but the note was either undated, untimed or unsigned. If so, they "gotcha". In this last category, the auditors are including illegible signatures submitted without a legend to reflect just whose signature is present. No matter how much quality health care is delivered by the physician, an absent or illegible signature will result in denied reimbursement. Fortunately, this is one of the easiest of all problems to fix.

For any requested records submitted by your office, you can either attach an attestation page confirming that you provided the care discussed in your note (with a legible signature, date and time) or alternatively, provide a "signature log" that includes your typed name, neat legible signature, scribbled signature usually found in your charts and/or you scribbled initials. One page or a copy is sufficient for the reviewer to confirm that all the notes submitted were performed by you and avoid unnecessary denials and appeals. Yes, this is a minor point and aggravating but it's one that public and private payers alike are focusing on to justify not properly paying for care. Please see a one page letter from Palmetto Carrier Medical Director Arthur Lurvey M.D. that follows for further comments in this regard.

We all know the importance of crossing the T's and dotting the I's. Simple attention to dating, timing and legibly signing all notes will result in better reimbursement.

Additionally, as I informed you recently, physicians across the country have been receiving demands for repayment from their Medicare carrier based on adjustments following from legislative changes included in last year's health care reform bill PPACA. Since most of these paybacks total no more than a few cents per case, Palmetto has bundled the claims until the aggregate is greater than $10.

Consequently, many of you have received demands for $50-$100 for as many as 50 different claims or more. Problems have occurred when the repayment is not made in a timely fashion. Because of the tremendous volume of repayments the Palmetto contractor has had to process, they are slow to log in your payments. However, the 45 day deadline before they start to withhold funds from future Medicare checks is unaltered. Therefore, if you hold the repayment letter for a few days and send your payment in close to the deadline, Palmetto may go ahead and withhold from their next payment to you and still cash your payment anyway. This can really lead to complicated bookkeeping.

An alternative strategy is to promptly authorize Palmetto to withhold the owed amount from future payments and then adjust the payment on your own books. This would avoid double payments and frustrating attempts to recover your own overpayment. You can download an "immediate offset" form from the Palmetto web site (www.Palmettogba.com/J1B) and fax it back to (803) 462-3916 to forestall this complicated bookkeeping back and forth. Alternatively, for a one time payment, you can simply fax a cover sheet with your authorization, name, phone, NPI, claim number and signature. I will forward an educational bulletin on this to the CUA web site as it becomes available from Palmetto. Please contact me for questions on these claw back demands for repayment if you think they are in error.

As usual, please contact me for clarification or assistance through the CUA email atinfo@cuanet.org
Jeffrey Kaufman, MD, FACS
CUA Representative
MedicareCarrier Advisory Committee

Avoiding Medicare Claim Denials

By Arthur Lurvey, MD
Medicare Contractor Medical Director, Palmetto GBA Jurisdiction 1

Palmetto GBA recently reviewed many Medicare claim denials denied by Palmetto and other Medicare contractors. The review unveiled that 54 percent of the denied claims were due to provider documentation related technical errors that can be easily avoided by submitting adequate documentation to support services as reasonable and medically necessary. The denial reasons of these claims can be categorized as following:

• Denial Reason #1: No medical record received after request for records.
  Resolution: When medical records are requested, send the records with a copy of the request within the time frame allowed on the request to the right contractor address.
• Denial Reason #2: No signature (or illegible signature) on documents and illegible medical records.
  Resolution: Progress notes and orders must be legible and signed. If the signature appears illegible, the office can create a signature page identifying the usual signature of the physician and attach it to the materials sent. If the signature is missing, the physician can send an attestation stating he or she actually saw the patient on the date of service in question
• Denial Reason #3: No time documented on timed codes.
  Resolution: When service time is part of a particular code (e.g., for some therapy, mental health claims, infusions, critical care, etc.), the time must be documented on the chart either in the format of 'from-to' or total time.
• Denial Reason #4: No record of medications given when medication billed on claim.
  Resolution: When medications or lab tests are billed, there must be some documentation (or order) to show the medication was administered and the test was wanted or needed.
• Denial Reason #5: Incorrect place of service on claim and incorrect use of new patient versus established patient.
  Resolution: The distinction between a new and an established patient is whether a patient was seen face to face by the provider within the last three years. Since some E/M codes are the same for 'office or other outpatient services', the correct place of service must be on the claim and match the documentation.

You control the documentation describing what services your patients received and your documentation serves as the basis for the services you bill to Medicare. If your documentation does not support the services on the claim, then a payment error exists.

We encourage you to take the proactive approach below to help reduce the payment error rate and avoid future claim denials.

• The response to a request for records should always be reviewed by an individual with clinical experience before submitting it to a Medicare contractor.
• Establish an office process and designate one individual responsible for all record requests.
• Use a checklist to verify if the progress notes were signed, legible, had the correct patient name and date, had the correct return address, etc.
• Always keep a record of the company and the contact asking for the record and when it is due. Whatever document was missing could be added by the physician (or other individuals with clinical background) before mailing or faxing the material.