July 2000
Volume 64 |
Number 7
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PRACTICE MANAGEMENT
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| Medicare Provides
Guidance on Voluntary Refunds of 'Overpayments' |
Karin Bierstein,
Practice Management Coordinator
Anesthesiologists concerned with potential liability for erroneous
Medicare billing know that the law requires a refund of overpayments
received. When a practice performs a self-audit that reveals past
problems, the question becomes, how can one refund the money received
in error without triggering an open-ended government investigation?
A recent Health Care Financing Administration (HCFA) program
memorandum gives the Medicare carriers some guidelines that will
help physicians structure their voluntary refunds. The questions
that carriers receiving unsolicited checks are instructed to ask
the physicians outline the information that the practice should
provide. (Whether to provide the information at the time of the
refund or later is a strategic decision to be resolved with counsel.)
When making a voluntary refund, the practice should plan to
explain:
- why the refund is being made;
- how it was identified;
- what sampling techniques were employed; what steps have
been taken to prevent future occurrences of the error leading
to the overpayments;
- the dates that the corrective actions were implemented;
- claims and claim information involved in the inappropriate
payments;
- the methodology used to arrive at the amount of the
refund; and
- "whether a full assessment was performed to determine
the entire time frame and the total amount of refund for the
period during which the problem existed that caused the refund."
The program memorandum directs carriers to investigate when an
unsolicited refund amounts to 20 percent or more of the total
annual Medicare payments to the practice in question. The carrier
must first perform a data analysis to identify any patterns of
payments for services not rendered for medically unnecessary services
or for upcoded services, among other problem areas. In deciding
whether to undertake further review, the carrier must also consider
whether the "refund accurately reflects the full disclosure of
the debt." The carrier may check the physician's compliance history,
e.g., whether the physician is currently the subject of either
a formal prepayment or postpayment review or any other potential
fraud and abuse examination. Depending on the results the carrier
may take corrective action itself such as provider education or
even creation of new local medical review policies. If the carrier
suspects fraud, it is required to refer the case to its internal
fraud unit.
Payments to Facilities for Pain Management Services
1. Pain Management Procedures Performed in an Ambulatory
Surgical Center (ASC)
Changes in the Current Procedural Terminology™ (CPT) codes
for epidural and nerve block injections have created much confusion
regarding Medicare payments to ASCs. Only those procedures (codes)
on the official ASC payment list generate a facility fee. If there
is no facility fee, the ASC may not permit the performance of
the procedures.
The 2000 edition of CPT deleted 11 codes and replaced them with
six new codes. Some carriers denied payment to the ASC for the
deleted codes, and some permitted the continued use of the old
codes. In May, HCFA distributed a program memorandum to the carriers
instructing them to pay for the replacement codes retroactively
to January 1 if ASCs appeal denials.
The 2000 edition of CPT also contained six brand-new codes that
did not directly replace existing codes, and those procedures
are not on the ASC list as corrected by the program memorandum.
Thus, those procedures -- cervical/
thoracic paravertebral facet joint and facet joint nerve injections,
transforaminal epidurals -- are not payable to the ASC, although
the physician will receive his or her professional fee. In fact,
since there is no facility fee, the physician should be able to
collect the "nonfacility" or office fee, which is considerably
higher than the facility fee. Since some ASCs are likely to put
a stop to the performance of the procedures, however, the higher
physician fee may not be a real option.
ASA is working together with other specialty societies and the
Federated Ambulatory Surgery Association to persuade HCFA to update
and correct the ASC list.
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PAIN CODES' ASC
PAYMENT STATUS:
|
| On the ASC List |
Not on the ASC list
|
| 62310 |
64470 |
64622 |
| 62311 |
64472 |
64623 |
| 62318 |
64479 |
64626 |
| 62319 |
64480 |
64627 |
| 64475 |
64483 |
|
| 64476 |
64484 |
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2. Hospital Outpatient Department Services Prospective
Payment System Finalized
The new prospective payment system under which Medicare will
reimburse hospitals for services performed in their outpatient
department went into effect on July 1, 2000. The final payment
amounts for nerve blocks and epidurals are only a few percentage
points higher than those that HCFA proposed in 1998. In its response
to formal comments filed by ASA and many other interested groups,
HCFA dismissed the concern that the grouping of all the epidurals
and nerve blocks into two "Ambulatory Payment Classifications"
(similar to the diagnosis-related groups, or DRGs, for inpatient
services) would grossly underpay some services, stating: "Because
all the services within the APC group are offered by most hospitals,
the impact of the variation in resource consumption should average
out at the hospital level" (Federal Register, April 7,
2000, page 18465).
The bottom line is that hospitals will now receive the following
flat fees for pain management procedures performed on an outpatient
basis:
| CPT Codes |
Payment Amounts |
| 62310, 62311, |
|
|
62318, 62319
|
$176.49 |
| 64400-64530, |
|
| 64600-64680 |
$160.98 |
Whether hospitals find these rates adequate to support a pain
service remains to be seen.
Although the rates are disappointing, the fact that there is
any allowance at all for the nerve blocks is a hopeful sign for
the future ASC payment system. Readers will recall that a HCFA
proposal to revamp ASC facility payments, which is still pending,
would take the nerve blocks off the list of procedures approved
for performance in an ASC. That would mean that they would not
be payable to the ASCs at all. Given HCFA's repeated assurances
that it wants to treat hospital outpatient departments and ASCs
consistently, we are optimistic that the nerve blocks will be
restored to the ASC list when the final rule appears. It is currently
expected to be published in November.
Source Materials:
Hospital Outpatient Department Rule:
http://www.hcfa.gov/regs/hopps/default.htm
HCFA Program Memorandum re ASC List: http://www.hcfa.gov/pubforms/transmit/AB002860.pdf
HCFA Program Memorandum re Voluntary Refunds: http://www.hcfa.gov/pubforms/transmit
/AB004160.pdf
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