Physician Audit Vulnerabilities Detailed in Medicare Article

Continuing its efforts to publicize valuable information derived from the RAC demonstration project, CMS released on December 2nd the fourth in a series of MLN Matters articles.
 

The latest, Special Edition article SE1036, provides education on two high-risk vulnerabilities for physician claims. According to CMS, claims were denied because the demonstration RACs determined that either a duplicate claim was billed and paid, or the physician reported an incorrect number of units for CPT codes billed based on the CPT code descriptor, reporting instructions in the CPT book, and/or other CMS local or national policy.
 

These RAC findings highlight the importance of the accuracy of the CPT code descriptions used in physician's charge documents (superbills), and should also discourage physicians from submitting charges repeatedly "just to be sure they weren't missed the first time."
 

Click here to read the entire MLN article.

United Healthcare Class Action Lawsuit

By now most physicians are aware of the class action lawsuit brought against UHC and its subsidiaries by the AMA and other plaintiffs.  The lawsuit alleges that UHC provided insufficient reimbursement for covered out of network (OON) services by:

• using flawed databases developed by Ingenix in determining reimbursement amounts for covered OON health benefits;
• using the OON reimbursement policies to reduce reimbursement amounts improperly for covered OON health benefits; and
• inadequately disclosing the use of the Ingenix databases and their OON reimbursement policies in determining reimbursement amounts for covered OON health benefits.

The most important thing to understand about this lawsuit is that it applies only to non-contracted providers, as only they could have provided out of network (OON) services.  Since the vast majority of PDS clients are contracted providers with UHC, this class action settlement does not apply to you.  For more information on this and other payer-related class action lawsuits, click here.

McKesson EHR Webinar Highlights

McKesson hosted a comprehensive 1-hour webinar covering the final ruling on "meaningful use" and the funding available to physicians who implement a qualified EHR in their practice. Contact PDS or click here for a copy of the presentation.