(Supplement)-Coders can help thwart Medicare 'bounty hunters'

Here's what you should know

Earlier this year, the government put out a bounty on health care providers and started offering weapons to senior citizens receiving health care.

This bounty is a $1,000-per-case reward the government is offering Medicare recipients to identify fraud in the health care system. In a series of sessions the government enlisted the American Association of Retired Persons to hold, attendees were given instructions by FBI agents and deputized by the federal agents to report suspected Medicare billing abuses on a toll-free hotline.

The evidence that patients may use is found on the Medicare Summary Notice (MSN) provided when a payment for health care has been made on behalf of beneficiaries to a hospital or other provider. Health care organizations should fight back by understanding the communication tools used by Medicare and by health service providers to address coverage for care and who should pay for it.

Playing a key role

Coding professionals have a key role to play in this process, so it is important to understand what the forms contain and how they relate to the billing process that uses our coding system.

The law regarding Notice of Medicare benefits is covered by Section 1804 of the Social Security Act. The notices provided since Jan. 1, 1998, include this explanation:

"A statement which indicates that because errors do occur and Medicare fraud, waste, and abuse is a significant problem, beneficiaries should carefully check any explanation of benefits or itemized statement furnished pursuant to section 1806 for accuracy and report any errors or questionable charges by calling a toll-free number."

That phone number is maintained by the Office of the Inspector General to receive complaints and information about waste, fraud, and abuse in the provision of billing of services.

Valid complaints could trigger investigation

Thus, your patients can become bounty hunters and trigger a full-scale investigation of your organization if their complaint has validity and a pattern of errant billings would emerge. For providers, the problem almost always has its roots in coding, whether it be an inaccurate Chargemaster with incorrect CPT-4 code maps or inadequately trained coding personnel.

There is good news, however, despite the vigilant efforts of the government. An adequate coding compliance program and aggressive data quality processes can prevent an attack by alert fraud-watchers of the Medicare set.

An understanding of what is contained in the MSN may help coding professionals become more knowledgeable of the outcome of their work and how it may impact the consumer.

Every provider should include reviews comparing what was paid to the expected reimbursement for a case, so that underpayments — as well as overpayments — or other errors can be identified and steps taken to prevent recurrence. Coding professionals should be familiar with the various formats so that this can occur efficiently.

The MSN is used to notify Medicare beneficiaries of action taken on intermediary and carrier processed claims. The MSN provides the beneficiary with a record of services received and the status of any deductibles. The MSN also informs the beneficiary of appeal rights.

The Medicare Intermediary furnishes an MSN to beneficiaries in most situations to describe health services claims made on their behalf to participating hospitals and other types of health care providers eligible for Medicare Part A benefits.

The MSN replaces the following documents:

Part A Medicare Benefit Notice, Form HCFA 1533, also known as the Part A Notice of Utilization sent for inpatient services

Explanation of Medicare Benefits Notice, sent for outpatient claims

Form HCFA 1954, Benefit Denial Letter (BDL) sent for partially denied claims

Form HCFA 1955, BDL sent for totally denied claims

Since HCFA eliminated benefit denial letters, Medicare beneficiaries will receive the information previously conveyed via BDLs through narrative messages contained on the MSN.

Providers will no longer receive a separate written notification, or copy of the BDL. Pro viders must use the coding information (such as ANSI reason codes) conveyed via the financial remittance advice to ascertain reasons associated with Medicare claims determinations affecting payment and applicable appeal rights and/or appeals information.

Generally speaking

The MSN is specifically designed as a summary notice to beneficiaries and is intended to be presented in an easily understood format. (See copy of MSN, inserted in this issue.) Coding professionals and health information managers should note that CPT-4 codes are included in the section where services provided are outlined for outpatient facilities.

Providers receive a summary voucher and check under procedures described in the Medicare Intermediary Manual §3702. This notice replaces the previous documents:

Part A Medicare Benefit Notice (HCFA 1533), also known as the Part A Notice of Utilization sent for inpatient services

Explanation of Benefits Notices sent to the patient for outpatient services

HCFA 1954, Benefit Denial Letter (BDL), sent for partially denied claims

HCFA 1955, BDL sent for totally denied claims

Notices are sent to beneficiaries for outpatient and inpatient claims combined into one notice every 31 days. The Intermediary must have the capability to issue the MSN in Spanish, as per beneficiary's request. Since the BDLs are no longer sent to patients, they receive this information through narrative messages contained on the Medicare Summary Notice.

The MSN contains the following sections:

Help stop fraud section.

Help stop fraud messages, found in the help stop fraud portion in the title section of the MSN, alert beneficiaries of local fraud scams. For example, if someone is illegally offering free food or other service in exchange for Medicare numbers, the Intermediary may design a message telling beneficiaries not to give out their Medicare numbers in exchange for free goods or services. Since space is limited in the help stop fraud section, the Intermediary may use the general information section for lengthy messages.

Claims processing messages.

Claims processing messages are specific messages related to the claims.They are found in the notes section of the MSN.

Deductible information.

Deductible information messages inform beneficiaries of the status of their deductible throughout the year. When the deductible has not been met, the patient will be responsible for payment for the amount up to the deductible.

General information.

The general information section is designed to inform beneficiaries of local health fairs and Medicare seminars, as well as to list those messages provided and those mandated by HCFA.

Appeals section.

The appeals section shows patients or their representatives what to do if they disagree with the claims decision and the time frame that would be required to initiate the process.

Another Medicare notice form that is routinely used by hospitals to inform patients of non-coverage of services is being revised. There is an Operational Policy Letter (OPL) available via the Health Care Financing Admin i stration Web site (www.hcfa.gov). You may download the OPL in either WordPerfect 6.1 or in PDF format. I have summarized it here for your reference.

There is some revised language for the Notice of Discharge and Medicare Appeal Rights (NODMAR) which previously was known as the Notice of Noncoverage (NONC).

This notice is used to inform beneficiaries in advance that Medicare does not cover the service ordered and that subsequent charges will be the patient's responsibility. This may include routine preventive care, or laboratory tests that are for screening rather than diagnostic purposes.

The sample form (see form, p. 137 and above) appears to address only inpatient notice of impend ing discharge. This letter does not make clear how the notice would be applied to outpatient facility circumstances in which non-covered services are provided. Physicians use the Advance Beneficiary Notice format for this purpose, but Intermediaries require a NONC for facility use. Some hospitals have revised this form for outpatient use in addition to the inpatient notices.

HCFA received complaints stating that the language contained in the current NONC is confusing to beneficiaries enrolled in Medicare managed care plans. In addition, the many variations of this notice have been reported to impose undue administrative burdens on both health plans and hospitals.

Therefore, HCFA has decided, after consultation with beneficiary groups, managed care plan, and provider communities, the model language for the NONC has been revised and its name changed to create a more "beneficiary-friendly" notice.

The Notice of Discharge and Medicare Appeal Rights (NODMAR), formerly known as the NONC, also is designed to inform Medicare enrollees, in a more streamlined and accurate manner, of their rights when they have received a hospital inpatient discharge decision. The NODMAR meets the notice requirements set forth in the existing Medicare regulations at 42 CFR 417.440(f) and the Medicare+Choice regulations at 42 CFR 422.620

HCFA says hospitals may use this model language or develop your own, but any NODMAR must include the following:

• the reason why inpatient care is no longer needed;

• the effective date of the enrollee's risk of financial liability;

• the enrollee's appeal rights.

Lastly, all NODMARs must be approved by your HCFA regional office plan manager. In the near future, HCFA will submit the model NODMAR to consumer testing to ensure that enrollees are able to understand their rights and how to exercise them when necessary.

Upon completion of this testing with beneficiaries, HCFA intends to develop this model language into a standardized NODMAR form and proceed with the OMB clearance process.