October 14, 2022 | By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC
Why is it that payors often, can’t or won’t comply with their own reimbursement rules or guidelines for processing/adjudicating claims? Some (who are contracted to The Centers for Medicare and Medicaid Services (CMS)) may view this blog in a negative light, but it doesn’t mean I don’t love you… it just means I don’t like when you expect providers of medical services to follow the rules of the Program Integrity Manual (PIM) but you refuse to!
There are so many areas I can pick on, such as the inability to comply with Section 8.4 Statistical Sampling and Extrapolation (Which will be my next Blog Post) but I want to specifically focus on Section 126.96.36.199 and my reason for this is because I am constantly inundated with emails and calls from people who have heard me speak at conferences or are clients/customers of DoctorsManagement (DM) and they’ve received a letter from a Medicare Contractor telling them they have been targeted for review of a random claim sample and they only have 15-days to comply with the demand. If they are a Medicare Contractor they are in violation of the PIM and the specific section mentioned above… Here is an example:
188.8.131.52 – Time – Frames for Submission (Rev. 628, Issued: 12-04-15, Effective: 11-16-15, Implementation: 01-06-16) This section applies to MACs, RACs, CERT, and ZPICs, as indicated.
- Prepayment Review Time Frames When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.
- Postpayment Review Time Frames When requesting documentation for postpayment review, the MAC, CERT and RAC shall notify providers that the requested documents are to be submitted within 45 calendar days of the request. ZPICS shall notify providers that requested documents are to be submitted within 30 calendar days of the request. Because there are no statutory provisions requiring that postpayment review of the documentation be completed within a certain timeframe, MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of submission extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.
Now, even though the MAC above in the example claims you have only 14 calendar days at the bottom of the letter to the client they try to cover their butt by providing the following:
So, the reality is you have 45-days to respond to the ADR and/or request an extension which they have the authority to grant under CMS Guidelines. Again, don’t confuse 184.108.40.206 with 220.127.116.11 which deals with failure to respond to an ADR:
18.104.22.168 – No Response or Insufficient Response to Additional Documentation Requests (Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) This section applies to MACs, RACs, CERT, and ZPICs/UPICs, as indicated.
- Additional Documentation Requests If information is requested from both the billing provider or supplier and a third party and no response is received from either within 45 calendar days for MACs and RACs or 30 calendar days for ZPICs/UPICs after the date of the request (or within a reasonable time following an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim, in full or in part, as not reasonable and necessary. Contractors shall use Group Code: CO – Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 – these are noncovered services because this is not deemed a “medical necessity” by the payer and Remittance Advice Remark Code (RARC) M127 – Missing patient medical record for this service. Contractors shall count these denials as automated review or non-medical record review depending on whether the denial is automated or requires manual intervention. For claims that had a PWK modifier, and the unsolicited documentation was reviewed, the review shall be counted as medical record review.
- No Response During prepayment review, if no response is received within 45 calendar days after the date of the ADR, the MACs, and ZPICs/UPICs shall deny the claim. During post-payment review, if no response is received within 45 calendar days after the date of the ADR (or extension), the MACs shall deny the claim as not reasonable and necessary and count these denials as non-medical record reviews. ZPIC/UPICs shall deny the claim as not meeting reasonable and necessary criteria if no response is received within 30 calendar days. RACs shall count these as complex or non-complex reviews.
- Insufficient Response If the MAC, CERT, RAC, or ZPIC/UPIC requests additional documentation to verify compliance with a benefit category requirement, and the submitted documentation lacks evidence that the benefit category requirements were met, the reviewer shall issue a benefit category denial. If the submitted documentation includes defective information (the documentation does not support the physician’s certification), the reviewer shall deny the claim as not meeting the reasonable and necessary criteria.
I realize these sections can get confusing and if you are not reading carefully enough you can make a very costly mistake such as rushing to send records because you believe you only have 14 calendar days when you actually have 45 days as well as the right to request an extension (unless it is a prepayment review) So, before you rush to send in your information check with someone who can ensure your rights under your participation agreement and prevent you from making a costly mistake.
Sean M. Weiss is a Partner and serves as the Vice President of Compliance for DoctorsManagement, LLC. Sean is the host of The Compliance Guy Podcast (www.thecomplianceguy.com) and provides strategic litigation defense services to law firms and healthcare entities across the country. Sean serves as a third-party compliance officer for numerous entities across the country. For more information please contact Sean at email@example.com or contact us at 800.635.4040.