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Reimbursement Questions
Whether you are experienced or new to reimbursement, all of us have questions. This section contains those questions that come up most often. In addition, if you have questions that are not listed here, you can contact us via e-mail or call us at 1-800-609-1083 and we will assist in finding your answer.
Reimbursement - Frequently Asked Questions:
Why does Medicare ask for provider medical records?
There are three common reasons:
- The contractor is gathering information from a number of offices to develop a baseline, an average, which is used to compare individual practice submissions.
- Your billing submission falls outside the baseline, which has been established.
- The majority of requests are made because the contractor thinks that you might be billing routinely for some services. They detect a repetition, or pattern to your billing, which raises questions.
Baseline
All contractors are required to study physician's billings to Medicare using statistics and data analysis. They use the current six (6) months and the previous six (6) months of submitted charges to Medicare. This process, called profiling, is the same for all contractors. First, the contractor looks at each service billed per specialty and finds the average billing. Then the contractor looks at the national billings for the same service, same specialty and finds the national billing average. The contractor takes the two (2) averages and then develops a baseline usage, per service, per specialty. For example, family practitioners billed an average of three (3) 99214's, per month to the local Medicare contractor. Nationally, all family practitioners billed an average of three (3) 99214's, per month to the entire Medicare Program. The baseline or norm for the contractor's review of 99214's, billed by family practitioners, is three (3), per month.
Contractors will request medical records from a very small sampling of providers within the baseline to make sure that the norm is valid. Clinical staff audits or reviews (terms used simultaneously in Medicare) medical records to ensure they are complete.
Outliers
Once the baseline is established, the contractor looks at, or profiles, each practitioner who requested payment from Medicare. Their charges are compared to the baseline, per specialty, per service. As an illustration, Dr. Jones is a physician in family practice. The contractor ran Dr. Jones' profile and found that in the past six (6) months Dr. Jones average number of 99214's submitted to Medicare is six (6), per month. This average is compared to the specialty of family practice, locally and nationally. In our case, the average number of visits, locally and nationally, is three (3), per month. Dr. Jones usage or utilization of services is six (6), per month and is outside the monthly baseline of three (3). Because Dr. Jones billings are outside of the average, they are considered outliers. Since Dr. Jones billed for more services than the norm, the contractor must order medical records to see if the conditions of Dr. Jones' patients warrant the extra services. Clinical staff reviews and determines if the documentation in the medical record supports the need for more services above the average. If the medical records fully document and support the additional services, then no further action is required. However, if clinical staff determines that there isn't enough information in Dr. Jones' medical records to support the extra services, then the contractor must determine what type of action it needs to take to correct a perceived deficiency in the medical record documentation. The number of claims and potential payment dollars will determine whether the contractor will do a one-on-one educational contact, overpayment assessment of all or part of past claims, suspension of all or part of future claim submissions, or a combination of all these actions.
Pattern Billing
Because contractors are required to study practitioners' charges submitted to Medicare, they could detect a pattern in your billings during the course of their analysis. Dr. Fleming is an internist. In the course of the data review, the carrier has noticed that 90 out of 100 of Dr. Fleming's patients have arthritis and Dr. Fleming always bills 99214 office visit for these patients. The contractor will wonder why this is happening. They will order medical records to eliminate the possibility of billing errors. Clinical staff will review the records and determine if they need to contact the provider for additional information or initiate one-on-one educational contact, overpayment assessment of all or part of past claims, suspension of all or part of future claim submissions, or a combination of all these actions.
The most common reasons for triggering a medical record request:
- The highest level of E&M code is billed routinely for the majority of patients, for example 99215 or 99233.
- The physician bills the same number of visits per patient for the majority of patients. All of Dr. Smith's patients receive four (4) visits a month, regardless of their condition.
- The exact same diagnosis is billed for the majority of patients.
- High dollar procedures are billed routinely and the billing exceeds the national norm.
- High volumes of services are billed and exceed the national norm. Dr. Pallor removes three times as many skin lesions as any other dermatologist in the country.
- The majority of billings are for non-covered or excluded services. (The contractors are required to review these billings to ensure the beneficiary is not inappropriately responsible for charges not paid by Medicare.)
- The provider consistently bills services that are coded incorrectly, for example hospital visit codes are billed, but the office is indicated as the place of service.
- The provider frequently bills for new technologies, usually using the unlisted procedure code, using 27299 or 92599.
- Referrals from other agencies, law enforcement, Internal Revenue Service, beneficiary or provider complaints.
- Once a baseline or norm for a particular specialty and service is established, providers within that norm are selected to validate the norm's accuracy.
If you should have any questions about these potential reasons for a
Medicare audit, please call DOXILine at 1-800-609-1083.
Date Created: 10/22/03
What are APCs?
APCs are Ambulatory Payment Classifications, a Medicare prospective payment system for the hospital outpatient setting. APCs were implemented in the hospital outpatient setting on 8/1/00. APCs do not impact physicians' offices. APCs are clinically consistent groups of items and services that receive a defined payment.
Date Created: 11/01/00
How is DOXIL paid under APCs?
DOXIL is paid under the Medicare APC system using its product specific J-
code (J9001 Doxorubicin HCl, all lipid formulations, 10 mg)
Date Created: 10/22/03
Can a patient have more than one APC per clinic visit?
Yes, a patient can have multiple APCs for each hospital outpatient clinic visit. There will be a separate APC for each procedure and / or pass-through drug received.
Date Created: 11/01/00
Will hospitals receive any payment in addition to the APC payment (Medicare portion plus patient co-pay)?
Yes. Hospitals will receive transitional payments, called TOPS, on a monthly basis to ensure they can continue to deliver services. These payments however are transitional and may not make up 100% of the difference in the payment that the hospitals were receiving before the implementation of APCs.
Date Created: 11/01/00
I would like to learn more about reimbursement? What can I do?
In our Resources section we have several documents that will help get you started.
Date Created: 11/08/00
Where can I find reimbursement information?
You can find reimbursement information in our Billing & Reimbursement section, as well as our Resources and FAQs.
Date Created: 11/28/00
Where can I find Medicare guidelines on a specific state?
State Medicare guidelines can be found in the Billing & Reimbursement section. Simply select your state/region from the left-hand navigation and let DOXILine.com do the rest.
Date Created: 11/08/00
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