Fix and File Gets Stay of Execution
What happens when a provider submits charges to a patient's health insurance company, but receives a denial notice due to a diagnosis that was miscoded—or missed all together?
In most cases, the provider will get paid if they resubmit it with the new or corrected information. However future resubmissions resulting in payment may be in jeopardy.
Back in February of 2005, the Centers for Medicare and Medicaid Services (CMS) revised the Medicare Program Integrity Manual (PIM) to prohibit the Medicare Carrier System from reviewing previously denied claims. According to Section 11.1.3 of the PIM, contractors deny a newly submitted line as "duplicate" if the contractor has:
- Already denied it for medical review (MR) reasons
- Medically reviewed, or
- Requested but did not receive documentation.
According to CMS PIM Transmittal 104, Change Request 3622, "Contractors shall also notify providers that, if a provider resubmits a line denied as a result of MR, the provider may not appeal the denial decision on the resubmitted line." The exception is if the provider documents that the service was not duplicative because it was performed more often than indicated in the original line. Generally however, there is little room for error; they have clearly closed the loopholes.
The effective date for this policy change was July 5, 2005; however, this date seemed to slip by some in the medical coding and billing field. In recent interviews, several well respected leaders in different areas of the country said they had not heard of the policy change, nor had they seen any impact in their normal routine.
It may have gone unnoticed because the change request prompted by PIM Section 11.1.3 is currently delayed, according to a Missouri Medicare Web site announcement dated October 27, 2005. Thankfully Missouri Medicare wants its providers to know the facts, and they provided a pop-up box with a link to the delay announcement. It can be found on their Web site at www.momedicare.com/provider/articles.aspx under "Fix and File." No other Part B carriers have any accessible Web information on this subject.
What does "delayed" mean? How long will the delay be? While we have been reprieved for now; sources at the Missouri Medicare did not wish to speculate on the future of this policy.
If you have a comment or question about the change request, please contact us.
Source Information
"What's New for Providers?" Missouri Medicare
http://www.momedicare.com/provider/articles.aspx
CMS Manual System, Transmittal 104, Change Request 3622
http://63.241.27.79/manuals/pm_trans/R104PI.pdf
Medicare Program Integrity Manual, Section 11.1.3
http://new.cms.hhs.gov/manuals/downloads/pim83c11.pdf
Telephone interviews of billing managers and practice administrators
Tamara O'Reilly, January 2006.
Fix and File Gets Stay of Execution
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