The return of related-claims denials?

ModeratorRoyModeratorRoy
in Part B Archive
Part B News did some reporting on this in 2014, and when CMS rescinded the order I thought that was that. But apparently some contractors are now fixing to deny surgical claims that are tied to hospital claims, if they can get approval first:



http://www.racmonitor.com/rac-enews/2144-denial-of-related-claims-to-broaden-with-new-name-cross-recovery.html



Any of you folks heard anything about this? It may be too early but you never know.



Thanks,

Roy
______________________________________________________________

Roy Edroso
Part B News
http://pbn.decisionhealth.com/

Comments

  • KarenHurleyKarenHurley
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    Direct from the article:



    First was Transmittal 505, which allowed contractors to deny all "related"
    claims when issuing a denial. This was quickly rescinded and then followed
    by Transmittal 534, 540, and finally 541. Transmittal 541 allows denial of a
    surgeon's claim if an inpatient surgery claim is denied for lack of medical
    necessity.

    But except in a few locations, such as Florida with total joint
    replacements, no auditor has denied a surgeon claim when the hospital was
    denied. While many in the case management and revenue cycle world secretly
    hoped that more auditors would start denying related claims so that
    physicians would have some skin in the game, it has not yet happened.

    That may start changing, as Noridian announced on July 12 that it would
    start performing "cross recovery" for related claims. In a statement the
    contractor indicated that "when medical review results in longstanding high
    error rates, the MAC (Medicare Administrative Contractor) may request CMS
    (Centers for Medicare & Medicaid Services) approval to deny 'related' claims
    submitted before or after the claim in question."

    The older I get, the more creativity I see by others in pondering Medicare's
    rules and regulations. Must be a way to earn a living, I guess.



    The first sentence baffles me as it isn't specific to what payee the
    'inpatient surgery claim' is - so I will presume the hospital (as stated in
    the 2nd paragraph).



    First - let's understand 'medical necessity.' This can only be assigned by
    the licensed provider, non-clinicians aren't able to do that (we provide
    resources to the provider). Second - the 'medical necessity' for the
    hospital stay is driven by the diagnosis code(s) provided by the admitting
    physician - and may have to be fine-tuned throughout the patient's hospital
    stay. Services and supplies provided during that stay can be an indicator
    of a change in status. Internal reviewers should be trained to look for
    variances in patient status to determine if the provider is giving
    additional information that will quantify (or extend) the stay - and query
    the physician.



    To automatically deny related claims because the hospital may not have done
    their investigative work for their part of the deal isn't appropriate, but
    to 'pend' the provider's claim might be valid, as it would put pressure on
    the hospital and/or physician to clean up the reason for the denial.





    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the
    recipient and the presented issue. It is not intended to be used as a
    global solution for future similar events. Reproduction of the information
    requires approval by the author.





    From: Roy Edroso [mailto:REdroso@decisionhealth.com]
    Sent: Thursday, September 08, 2016 9:54 AM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] The return of related-claims denials?



    Part B News did some reporting on this in 2014, and when CMS rescinded the
    order I thought that was that. But apparently some contractors are now
    fixing to deny surgical claims that are tied to hospital claims, if they can
    get approval first:

    http://www.racmonitor.com/rac-enews/2144-denial-of-related-claims-to-broaden
    -with-new-name-cross-recovery.html

    Any of you folks heard anything about this? It may be too early but you
    never know.

    Thanks,
    Roy

    ______________________________________________________________



    Roy Edroso

    Part B News

    http://pbn.decisionhealth.com/










    * * *
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    Direct from the article:

     

    First was Transmittal 505, which allowed contractors to =
    deny all “related” claims when issuing a denial. This was =
    quickly rescinded and then followed by Transmittal 534, 540, and finally =
    541. Transmittal 541 allows denial of a surgeon’s claim if an =
    inpatient surgery claim is denied for lack of medical =
    necessity.

    But except in a few locations, such as Florida with total =
    joint replacements, no auditor has denied a surgeon claim when the =
    hospital was denied. While many in the case management and revenue cycle =
    world secretly hoped that more auditors would start denying related =
    claims so that physicians would have some skin in the game, it has not =
    yet happened.

    That may start changing, as Noridian announced on July 12 =
    that it would start performing “cross recovery” for related =
    claims. In a statement the contractor indicated that “when medical =
    review results in longstanding high error rates, the MAC (Medicare =
    Administrative Contractor) may request CMS (Centers for Medicare & =
    Medicaid Services) approval to deny ‘related’ claims =
    submitted before or after the claim in =
    question.”

    The older =
    I get, the more creativity I see by others in pondering Medicare’s =
    rules and regulations.  Must be a way to earn a living, I =
    guess.

     

    The first sentence baffles me as it isn’t =
    specific to what payee the ‘inpatient surgery claim’ is =
    – so I will presume the hospital (as stated in the 2nd =
    paragraph). 

     

    First =
    – let’s understand ‘medical necessity.’  =
    This can only be assigned by the licensed provider, non-clinicians =
    aren’t able to do that (we provide resources to the provider). =
     Second – the ‘medical necessity’ for the =
    hospital stay is driven by the diagnosis code(s) provided by the =
    admitting physician – and may have to be fine-tuned throughout the =
    patient’s hospital stay.  Services and supplies provided =
    during that stay can be an indicator of a change in status.  =
    Internal reviewers should be trained to look for variances in patient =
    status to determine if the provider is giving additional information =
    that will quantify (or extend) the stay – and query the =
    physician.

     

    To automatically deny related claims because the =
    hospital may not have done their investigative work for their part of =
    the deal isn’t appropriate, but to ‘pend’ the =
    provider’s claim might be valid, as it would put pressure on the =
    hospital and/or physician to clean up the reason for the =
    denial.

     

     

    Karen A. Hurley, BS, CMM, CPC, =
    CNA

    President, =
    HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

     

    Since 1996, Celebrating 20 =
    years of Service to Physicians

     

    Disclaimer:  Advice or comments given in this email are =
    specific only to the recipient and the presented issue.  It is not =
    intended to be used as a global solution for future similar =
    events.  Reproduction of the information requires approval by the =
    author.

     

     

    From: Roy Edroso =
    [mailto:REdroso@decisionhealth.com]
    Sent: Thursday, September =
    08, 2016 9:54 AM
    To: Multiple recipients of list PARTB-L =
    <partb-l@list.partbnews.com>
    Subject: [partb-l] The =
    return of related-claims denials?

     

    Part B News did some reporting on this in 2014, and when CMS rescinded the order I =
    thought that was that. But apparently some contractors are now fixing to =
    deny surgical claims that are tied to hospital claims, if they can get =
    approval first:  http://www.racmonitor.com/=
    rac-enews/2144-denial-of-related-claims-to-broaden-with-new-name-cross-re=
    covery.html     Any of you folks heard anything about this? It may be too early but you =
    never know. Thanks,Roy

    ___________________________________________________________=
    ___

     

    Roy =
    Edroso

    Part B =
    News

    http://pbn.decisionhealth.com/=

     

     

     

     

     * * *Part B-L is sponsored by Part B =
    News (www.partbnews.com), which =
    is published by DecisionHealth (http://www.decisionhealth.com)=
    . Call us toll-free =
    877-602-3835 To =
    unsubscribe: Go to http://www.decisionhealth.=
    com/partb-l    ; Type in your email address; Click “My =
    Forums”; Click =
    “unsubscribe” Going on vacation? Set your membership to no email. Here’s how: =
    http://www.decisionhealth.=
    com/partb-l    ; Type in your email address; Click “my =
    account”; Look for “Membership type” and click the =
    arrow next to the box; Select no email; Click “save =
    changes”; Click “log =
    out.” If you =
    belong to more than one of our forums, simply click on one of the forums =
    and follow the same directions as above. The selection you make, e.g., =
    “no email,” should apply to all of your =
    forums. To post to this =
    list, use partb-l@list.partbnews.com=

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  • ModeratorRoyModeratorRoy
    edited May 2017
    Karen,

    No argument from me! We'll see what they actually do. Noridian was pretty terse:

    https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/cross-recovery



  • KarenHurleyKarenHurley
    edited May 2017
    This is a multipart message in MIME format.

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    Looks like it is related to specific CPT codes, which - in my opinion -
    could only be addressed for medical necessity by the professional
    association representing the specialty of the providers.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians






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