Medicare has been incorrectly recouping some payments to providers — or denying their claims — because the patient involved was believed to be incarcerated, the Centers for Medicare and Medicaid Services (CMS) admitted Tuesday.
To address the problem, CMS is working with claims data to identify incorrectly dinged payments and change its processing system, agency officials said in an open door telephone forum with physicians.
This process to identify claims denied in error and then reprocessing them will be completed by the Medicare Administrative Contractors, Louisa Rink of CMS said, reading from a frequently asked question (FAQ) document CMS recently updated.
The agency previously recovered paid claims for individuals thought to be incarcerated at the time of service. Medicare generally won’t pay for medical care given to patients in custody or incarcerated at the time of service.
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However, CMS has since learned much of the information was “incomplete for purposes of collection” and may have resulted in recovering payments that were correctly paid.
The agency had worked with the Social Security Administration to identify when a patient would have been incarcerated.
“CMS understands that this issue has been challenging for providers, and we are actively addressing it,” Rink said.
The agency has no firm target date for correcting the issue, but Rink said it won’t be done by October. Providers may appeal CMS’ recoupment of money, but are not required to, she said.
She couldn’t answer whether a claim was payable if a patient was treated in the morning and incarcerated later in the day.
The American Medical Association, in a letter to CMS Administrator Marilyn Tavenner on Friday, urged CMS to stop its recovery efforts, recognizing there have been errors in recovery.
“Instead, CMS should take action to improve the process used to identify periods of incarceration and clarify denial forms and notices so that providers are aware of the explicit reason justifying a recoupment,” the letter read.
The AMA also opposed any “burdensome” requirement placed on providers to confirm a patient’s incarceration status, such as calling their Medicare Administrative Contractor.
The definition of incarcerated is broad and includes people on parole, supervised release, medical furlough, residing in a mental institution, or other similar situation, the letter said.
“CMS should finalize clear, bright-line guidance to educate providers going forward regarding these types of claims,” the AMA said.
In another topic on Tuesday’s CMS forum, the agency recognized problems providers were having billing for its new transitional care management codes — the CPT code physicians may bill under for helping a patient transition back to the community after discharge from a facility. Chris Ritter, PhD, director of the division of outpatient care at CMS, didn’t specify the problems providers were having.
“In addition to looking at what we can do, we also have an FAQ up and have an announcement coming out about how you can order hard-copy information on billing for transitional care management,” said Ritter.
The agency also encouraged providers to do more than just be aware of new patient coverage options under the Affordable Care Act, so they can help steer patients toward coverage.
“We all need to make sure we’re as educated about this as we can be so that we can help people take advantage of expansion in January,” said William Rogers, MD, director of CMS’ Physician Regulatory Improvement Team.
Date: August 29, 2013