Knowledge Base Article

MEDICARE ADMINISTRATIVE CONTRACTORS (MACS)

There were no new Targeted Probe and Educate (TPE) medical reviews affecting hospitals announced by the Medicare Administrative Contractors (MACs) recently. Novitas JH and JL did release some additional TPE results recently including results for Denosumab, IVIG, HBO, therapy services and DRG validation. Error rates for all of the Novitas reviews were low.

Providers should look for learning opportunities associated with the TPE program on their MACs’ websites or listservs. For example, the Novitas findings referenced above include reasons claims for these services were denied. MACs also sometimes offer educational webinars or teleconferences related to the TPE topics. Palmetto GBA is hosting a Part A Ask the Contractor Teleconference (ACT) on Wednesday, September 18, 2019, at 11 a.m. ET about DRG 682 – Renal Failure. For more information see this Palmetto link.

RECOVERY AUDITORS (RACS)

All Recovery Auditors added a complex review issue for Intravenous Immune Globulin for the Treatment of Autoimmune Blistering Diseases: Medical Necessity and Documentation Requirements. According to the Cotiviti website, “Medical documentation will be reviewed to determine if the use of intravenous immune globulin meets Medicare coverage criteria and is medically reasonable and necessary.” Cotiviti lists the issue twice but indicates both listings are for Region 2. This is likely a typographical error.

SUPPLEMENTAL MEDICAL REVIEW CONTRACTOR (SMRC)

Noridian, the current SMRC, added issues for outpatient hyperbaric oxygen therapy (HBO) and for spinal cord stimulators. They also added some issues for ambulance services. You can view all the current SRMC issues here.

OFFICE OF INSPECTOR GENERAL (OIG)

The August update of the OIG Work Plan included several issues relative to services that could be performed in and billed by hospitals.

• Review of the Medicare DRG Payment Window – “Outpatient services directly related to an inpatient admission are considered part of the inpatient payment and are not separately payable by Medicare.”
• Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays – “An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records.”
• Review of Medicare Facet Joint Procedures – “We will review whether payments made by Medicare for facet joint procedures billed by physicians complied with Federal requirements.”