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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 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.
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.
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).
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.
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.
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.
Where can I find reimbursement information?
You can find reimbursement information in our Billing & Reimbursement section, as well as our Resources and FAQs.
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® do the rest.
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 INDICATIONS AND IMPORTANT SAFETY INFORMATION
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Indications for DOXIL® (doxorubicin HCl liposome injection)
- DOXIL® (doxorubicin HCl liposome injection) is indicated for the treatment of patients with ovarian cancer whose disease has progressed or recurred after prior platinum-based therapy
- DOXIL® in combination with VELCADE® (bortezomib) is indicated for the treatment of patients with multiple myeloma who have not previously received VELCADE® and have received at least one prior therapy
Important Safety Information for DOXIL® (doxorubicin HCl liposome injection)
BOXED WARNINGS:
Cardiotoxicity, infusion reaction, myelosuppression, liver impairment, substitution
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The use of DOXIL® may lead to cardiac toxicity. Myocardial damage may lead to congestive heart failure and may occur as the total cumulative dose of doxorubicin HCl approaches 550 mg/m2
- Prior use of other anthracyclines or anthracenediones should be included in calculations of total cumulative dose
- Cardiac toxicity may also occur at lower cumulative doses (400 mg/m2) in patients with prior mediastinal irradiation or who are receiving concurrent cyclophosphamide therapy
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Acute infusion-related reactions including, but not limited to, flushing, shortness of breath, facial swelling, headache, chills, back pain, tightness in the chest or throat, and/or hypotension have occurred in up to 10% of patients treated with DOXIL®. In most patients, these reactions have resolved within several hours to a day once the infusion is terminated. In some patients, reactions resolved with slowing of the infusion rate
- Serious and sometimes life-threatening or fatal allergic/anaphylactoid-like infusion reactions have occurred. Medications to treat such reactions, as well as emergency equipment, should be available for immediate use
- The initial rate of infusion should be 1 mg/min to minimize the risk of infusion reactions
- Severe myelosuppression may occur
- DOXIL® dosage should be reduced in patients with impaired hepatic function
- Accidental substitution has resulted in severe side effects. Do not substitute for doxorubicin HCl on a mg per mg basis.
Contraindications
- Patients with a history of hypersensitivity reactions to a conventional doxorubicin formulation or the components of DOXIL®
- Nursing mothers
Additional Safety Information
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Cardiac function should be carefully monitored
- Congestive heart failure or cardiomyopathy may occur after discontinuation of anthracycline therapy
- For patients with a history of cardiovascular disease, or if the results of cardiac monitoring indicate possible cardiac injury, the benefit of therapy must be weighed against the risk of myocardial injury
- In the randomized multiple myeloma study, 25 patients (8%) in the VELCADE® for Injection arm and 42 patients (13%) in the VELCADE® plus DOXIL® arm experienced left ventricular ejection fraction decrease (defined as absolute decrease > 15% over baseline or a > 5% decrease below institutional lower limit of normal)
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Myelosuppression may occur; frequently monitor complete blood count (including platelet count), at least prior to each dose of DOXIL®
- In patients with recurrent ovarian cancer, hematologic toxicity (based on platelet count or absolute neutrophil count) may require dose reduction or delay in administration of DOXIL®
- In patients with multiple myeloma, hematologic toxicity (based on platelet count, absolute neutrophil count, hemoglobin level, or neutropenia with fever) may require dose reduction, delay in administration, or suspension of DOXIL® and/or VELCADE®
- Persistent severe myelosuppression may result in superinfection, neutropenic fever, or hemorrhage
- Sepsis occurring during neutropenia has resulted in discontinuation of treatment and in rare cases of death
- DOXIL® may potentiate the toxicity of other anticancer therapies, especially hematologic toxicities, when used in combination with other therapies that suppress bone marrow
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Hand-foot syndrome (HFS) may occur during therapy with DOXIL®
- Based on HFS toxicity grade, dose reduction, delay in administration, or discontinuation of DOXIL® may be required
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HFS was generally observed after 2 to 3 cycles of treatment, but may occur earlier
- The reaction was mild in most patients, resolving in 1 to 2 weeks
- The reaction can be severe and debilitating in some patients, resulting in discontinuation of therapy
- DOXIL® is an irritant, not a vesicant; use precautions to avoid extravasation
- DOXIL® can cause fetal harm when used during pregnancy
- Recall reaction has occurred with DOXIL® administration after radiotherapy
- DOXIL® may interact with drugs known to interact with the conventional formulation of doxorubicin HCl
- In patients with recurrent ovarian cancer, the most common all-grade adverse reactions (ARs) > 20% (DOXIL® vs topotecan, respectively) included: asthenia (40% vs 51%), fever (21% vs 31%), nausea (46% vs 63%), stomatitis (41% vs 15%), vomiting (33% vs 44%), diarrhea (21% vs 35%), anorexia (20% vs 22%), dyspnea (15% vs 23%), HFS (51% vs 1%), and rash (29% vs 12%)
- In addition, 19% vs 52.3% reported alopecia (all grades)
- Grade 3/4 hematologic ARs reported in > 5% (DOXIL® vs topotecan, respectively) were neutropenia (12% vs 76%) and anemia (6% vs 29%)
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In patients with multiple myeloma, the most common all-grade ARs > 20% (VELCADE® plus DOXIL® vs VELCADE®, respectively) included: neutropenia (36% vs 22%), thrombocytopenia (33% vs 28%), anemia (25% vs 21%), fatigue (36% vs 28%), pyrexia (31% vs 22%), asthenia (22% vs 18%), nausea (48% vs 40%), diarrhea (46% vs 39%), vomiting (32% vs 22%), constipation (31% vs 31%), mucositis/stomatitis (20% vs 5%), peripheral neuropathy (42% vs 45%), neuralgia (17% vs 20%), and rash (22% vs 18%)
- In addition, 19% vs < 1% reported HFS
Please click here for DOXIL® full Prescribing Information, including Boxed WARNINGS.
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