Most medical providers naturally assume that Medicare personnel review claims before authorizing and sending reimbursements. While their staff attempts to ensure accuracy, Medicare sometimes sends excess claims payments.
As the nation’s population ages, the volume of claims and the number of covered citizens has grown to exorbitant proportions. These realities increase the probabilities of billing errors, overlooked review mistakes and, in some cases, excess reimbursements.
ICD-10 and Medicare Reimbursements
The coming move from ICD-9 to ICD-10 billing codes may increase the number of incorrect Medicare reimbursements, possibly increasing denials, along with excess payments. With thousands of new codes, medical billing and claims personnel face learning curve challenges that will take a while to overcome and perfect.
Medicare procedures are complex. Billing personnel must be thoroughly trained in these procedures to improve the accuracy of claims submissions and generate timely reimbursement. Practice managers must ensure that billing staff is as trained as humanly possible in the new codes as they relate to Medicare claim submission procedures.
Excess Payment Time Limits
Whether the error generating excess reimbursement is the mistake of a medical provider or Medicare staff, the medical practice must return the excess payment within 60 days. Potentially severe penalties can result from non-compliance with this requirement.
Medical providers naturally are often unhappy that the burden of review and audit falls to the physician, support professionals or practice staff. However, avoiding an unannounced visit from enforcement personnel from the Office of the Inspector General supersedes the annoyance of reviewing reimbursements for accuracy.
Dealing with Excess Medicare Payments
At the great risk of overstating the obvious, the most effective method of dealing with excess Medicare payments is to avoid them. Having fully trained and diligent billing staff can avoid most, but not all, claim submission errors and excess Medicare payments. Even if you've created a trained, committed billing department, take these relatively simple steps to deal with excess Medicare payments.
- Fully train billing staff in Medicare procedures. According to the Centers for Medicare and Medicaid Services (CMS) the cause of many excess payment errors originates with billing personnel or medical providers lacking full understanding of Medicare procedures. Spending over $64 billion annually on doctors and medical personnel, Medicare cannot be perfect in every aspect of their payments. Having billing staff that understands all Medicare procedures helps minimize excess payments and resolve issues when they occur.
- Be clear with the components of reimbursement determination. Understanding components of Medicare reimbursements helps identify and resolve excess payment problems. The Resource-Based Relative Value Scale (RBRVS) determines how medical providers are reimbursed. Medicare payments are based on four factors, including physician’s services (52 percent), estimated practice operating expenses (44 percent), cost of professional liability insurance (4 percent) and payment reimbursement adjustments for geographical location cost-of-living differences.
- Determine the accuracy of the submitted claim and the payment amount. Have staff audit the contents of each claim and reimbursement. Personnel familiar with Medicare reimbursement policies and procedures can verify the accuracy or identify errors in coding or submission documentation. Determining if the payment amount is correct or excessive is more black and white than gray; it’s correct or it isn’t.
- If the reimbursement is correct, contact Medicare to “plead your case.” Explain to Medicare customer service why the submission is correct as is the reimbursement amount.
If the Medicare payment is excessive, submit a corrected billing and return the excess payment to Medicare. Correct all billing errors and submit the proper claim. You should receive timely payment. You’ll avoid penalties and receive payment.
Taking these protective actions help you avoid expensive penalties and receive timely Medicare payments.
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