Physician Accountability in Medicare Billing

Medicare Set-Aside Blog on June 15, 2012 | Posted by


Physicians have been the subject of many of my recent rants because so many of the problems that we encounter with MSP issues can be attributed directly to them. We can’t control their excessive treatment plans or lazy billing practices, but neither can we convince CMS that these problems exist. In conditional payment recoveries, it is impossible to get CMS to adjust its recovery to account for commingled billing. Physician billing offices will frequently reuse forms pre-filled with patient information, including all diagnosis codes ever treated by that physician whether during that visit or not. From their perspective, it doesn’t matter because they do not get paid by the treatment, but by the time spent. Unfortunately for those on the other end of that transaction, it makes a huge difference and the private sector has been absorbing those payments for the benefit of Medicare for many years. The other issue is indifference in who gets billed. Patients don’t understand that it makes a difference who gets billed and physicians doesn’t care who pays so long as someone pays. Many of what are deemed conditional payments are not conditional at all – they were made by mistake due to lack of notice of secondary payer issues. But the one thing that all of these scenarios have in common is that the problems all originate in the physician’s billing office. Well, perhaps no more…

CMS has recently made changes to the Medicare Secondary Payer Manual to add “Clarification of Medicare Conditional Payment Policy and Billing Procedures for Liability, No-Fault and Workers – Compensation Medicare Secondary Payer (MSP) Claims.” Included in Transmittal 86 are several comprehensive changes for provider billing requirements when the common working file (CWF) indicates an MSP situation. Interestingly, many of the new provisions also include looking to see if there is a GHP that is primary to Medicare as well and waiting for the promptly period to expire before making conditional payments. It is clear that CMS intends to hold providers more accountable for determining MSP exclusions.

While not anything that will affect us from an MSP compliance standpoint, understanding the new changes does give some insight into the post-settlement world the Medicare beneficiaries will face once tagged with MSP exclusions which will be particularly helpful to the attorneys representing them in insurance settlements. Between this and the new proposed rules for future medicals, it is obvious that CMS is finally wrapping its brain around MSP enforcement. So hold on tight, this ride is about to get a whole lot more interesting.

Changes don’t go into effect until essentially 2013. It is unclear when the MSP Manual chapters effected will be updated; however, Transmittal 86 can be found here in the interim.