REIMBURSEMENT & CODINGNEWS refused documentation by a referring / ordering physician , please report the incident as potential fraud and / or abuse . As a referring / ordering physician , if you are asked to sign or write prescriptions for Medicare beneficiaries by a provider / supplier for unnecessary services / items or for patients you do not know , please report the incident .
To report potential Medicare fraud and abuse please review the OIG or Stop Medicare Fraud websites for multiple ways to report :
http :// oig . hhs . gov / fraud / report-fraud / index . asp
http :// www . stopmedicarefraud . gov / index . html
You can also call the OIG Hotline at 1-800-HHS-TIPS ( 1-800-447-8477 ).
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The definition of physician is found at http :// www . socialsecurity . gov / OP _ Home / ssact / title18 / 1861 . htm # act-1861-r .
Only One Electronic Remittance Advice Recipient Per NPI / Legacy ID Starting April 1 , 2012
Prior to the implementation of the Healthcare Integrated General Ledger Accounting System ( HIGLAS ), Medicare ’ s Multi-Carrier System ( MCS ) created just one check per sender , National Provider Identifier ( NPI ), or legacy ID . Each sender / NPI / legacy ID was able to have multiple receivers of the electronic remittance ; MCS would use the sender ID submitting each claim to aid in determining to whom the remit should be sent . For each check that was created , MCS also created an electronic remittance advice ( ERA ), which accurately reported the payment amount for that ERA .
When a MAC transitions to HIGLAS ,
Therapeutic Shoes – 4th Quarter 2011 Prepayment Review Update
National Government Services , the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor ( DME MAC ) Medical Review department continues to conduct a prepayment targeted medical review for therapeutic shoes . This is a selection of multiple supplier submitted claims based on a targeted service ( s ) that are reviewed for medical necessity .
As of 12 / 31 / 11 , a total of fifty-four ( 54 ) claims were captured for review and developed for additional documentation . All of these claims have been reviewed and processed . Of these , 50 claims were denied ( 92.60 % claim error rate ). Below continue to be the top two ( 2 ) reasons for denial .
Reasons
No documentation received 48 % Denied as non covered 34 %
The top issues causing these denials are :
• Not responding to request for documentation letter in the required timeframe
• No or insufficient medical records submitted from the certifying physician to substantiate qualifying foot condition
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Therapeutic Shoes Local Coverage Determination ( LCD ) ( L27040 ) and Policy Article ( A47129 ). Ensure when submitting additional documentation , that all medical necessity documentation is current for the date of service . Supplier responses should also be submitted timely . Suppliers can review the Therapeutic Shoes LCD for all DME MAC jurisdictions on the PFA website at www . pedorthics . org , and clicking to the Information for DMEPOS Suppliers Section . Suppliers may also find useful information and articles on the National Government Services Web site under Education and Training – Clinical Education .
only one check can be produced per NPI / legacy ID . The old MCS system logic , which took the sender information into account when generating the remit , was not changed when MACs began their transition to HIGLAS ; in some instances , the result was a remittance advice that did not contain all of the claims processed in a given cycle or a remittance advice containing payments that did not total to the EFT / check amount .
In order to accurately produce electronic remittance advices to match the EFT /
% of claims completed
check amount , MCS will be changing their logic effective Sun Apr 1 , 2012 – and will no longer consider the sender information when creating the ERA files . MACs will allow only one receiver of an electronic remittance per NPI / legacy ID regardless of whether the provider submits their inbound files under different sender IDs . Your respective MAC will be contacting you if you are set up on their files for multiple receivers of the ERA , in which case you will need to select one receiver for your electronic remittance .
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