AdvanceMed, as the Medicare Program Safeguard Contractor, is required to conduct periodic data analysis to identify potential claim payment errors. Data analysis compares claim information and other related data to identify potential errors and/or potential fraud by claim characteristics (e.g., diagnoses, procedures, providers or beneficiaries) individually or in the aggregate.
Recent data analysis was conducted to identify duplicate facility payments issued to an ASC and an outpatient facility for the same surgical procedure. This review looked for instances when the same surgical procedure was performed for the same patient and on the same date of service and by the same surgeon.
Review of the data confirmed that ASCs and outpatient facilities both submitted claims to Medicare for reimbursement of the facility charges. The ASC submitted charges to the Part B carrier and the outpatient facility submitted charges to the Part A Fiscal Intermediary.
Reimbursement to both entities should not be issued unless the patient's medical records can substantiate that two separate procedures were performed at different times in different operating suites. When the services cannot be supported through the medical records, an overpayment has occurred and must be refunded to Medicare by the responsible party.
If your facility submits claims to a carrier or intermediary for facility charges, AdvanceMed suggests that your facility perform a self-audit to determine if the above scenario has occurred. Medicare guidelines indicate that errors resulting in overpayments must be reported and refunded to the carrier or intermediary that issued the payment. Providers are encouraged to include a copy of this article to assist in the explanation of the refund.
We would also like to suggest that your facility develop safeguards to efficiently prevent or address potential errors as the one identified in this notice. We have noted some safeguard procedures that may assist you in this process:
- Verify the correct patient health insurance claim number was submitted on the claim
- Verify the surgical procedure was actually performed on the date as submitted
- Validate the location where surgical procedure was performed and verify the correct designation, outpatient or ASC
- Verify that all the surgical services submitted are reflected in the patient's medical records/operative report
- Internal audits should be periodically and regularly conducted on outpatient surgical claims to ensure the proper place of service was submitted
- If your facility has an affiliation with an ASC, precautions should be taken to prevent erroneous billings between the two entities
last updated on 01/18/2006