Current Status

9/13/2018: Providers who have exceptions they feel are warranted may continue to submit them to Palmetto GBA for consideration. 

Submitting Exception Requests: If you believe you have a valid exception request: 

  • You may send an email to jj.prrs@palmettogba.com notifying us and indicating the specific claim identifiers (DCNs) and related documentation you are prepared to submit. If the documentation is NOT PHI/PII based, please proceed with attaching and submitting it with your email.
  • You may submit a request via the eServices online provider portal at www.palmettogba.com/eservices via the general inquiry form notifying us and indicating the specific claim identifier (DCNs) and you may include the related documentation even if it includes PHI/PII based information 

The following are some examples (not exhaustive of all possible forms) of appropriate documentation:

  • Copy of the cancelled check if payment was already sent and processed for these identified overpayments
  • Credit Balance Report documentation showing the listing of claims you previously submitted with your report and requested to have cancelled
  • Proof of delivery receipt to Cahaba GBA 

The following are examples of submissions that have NOT  been granted an exception:

  • Providers who are no longer in business requested an exception for overpayments that occurred while they were in business
  • Providers identified claims as being paid by fee-for service Medicare as secondary which were determined to have processed as Medicare primary
  • Providers advised claims as processed appropriately under Medicare fee-for-service but for which a Medicare Advantage plan was determined to be in effect for those dates of service

Situation:
The information included in this CPIL issue was originally posted in an article on May 7, 2018, and revised on May 15, 2018.

Palmetto GBA has identified potential overpayments for claims processed prior to February 2018, related to Part A Jurisdiction J claims that were paid for Medicare beneficiaries covered under an MA Plan. Below, we have listed the limited scenarios that would warrant the claim being submitted to Fee For Service (FFS) Medicare.

  • If a patient is enrolled in an MA Plan; the hospital or SNF would submit an inpatient claim with a condition code 04 or a teaching hospital would submit a condition code 04 and 69 in order to capture the benefit period. There would be no payment on the inpatient claim; however, if they were billing Indirect Medical Education (IME) FFS Medicare would pay the IME.
    • MA Plan covered period outpatient claims would never be billed to FFS Medicare.
  • If the MA Plan beneficiary elects Hospice, then their claims are no longer the responsibility of the MA Plan. The patient has FFS Medicare for the time they are enrolled in Hospice. The hospital bills the hospice for all inpatient/outpatient terminal illness related services and bills FFS Medicare for all inpatient/outpatient service not related to Hospice with a condition code 07. FFS Medicare pays for the non-related services until the beneficiary revoked/deactivated hospice; then the MA Plan picks up again.
  • If the MA Plan beneficiary joins a qualifying clinical trial, FFS Medicare pays for the costs of routine services. Please refer to MLN Matters® Number: SE1344 (PDF, 73 KB) for proper billing instructions.
  • If the beneficiary is in an inpatient stay and his enrollment in the MA plan takes after the stay begins, but prior to the discharge from that stay, FFS Medicare would pay for the inpatient stay.

For additional information, refer to the full list of exceptions to requirements (PDF, 522 KB) for MA plans to Cover FFS Benefits. Palmetto GBA developed a list of questions and responses for providers that address Medicare Advantage (MA) Overpayments. Please review these FAQs.

Impact to Providers:
This article serves as our intent to provide notice that we plan to reopen Medicare’s initial determination of claims erroneously paid within four years of the date of this notice (May 7, 2018). The decision to reopen for good cause is in accordance with 42 CFR 405.986 and based on evidence that an obvious error was made at the time of the initial determination. Providers with claims subject to the above reopening will be contacted directly and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan.

As required by 42 CFR 401.305 a provider/supplier who has received an overpayment must report and return the overpayment within 60 days after having identified the overpayment. (The overpayment can also be reported and returned by the date any corresponding cost report is due, if applicable). This requirement applies to overpayments identified within six years of the date the overpayment was received. In addition, when a government agency informs a provider/supplier of a potential overpayment, the provider/supplier has an obligation to accept the finding or make a reasonable inquiry to determine whether an overpayment exists and whether any similar overpayments exist within the six year lookback period.

Status:
9/13/2018: Providers who have exceptions they feel are warranted may continue to submit them to Palmetto GBA for consideration. 

Submitting Exception Requests: If you believe you have a valid exception request: 

  • You may send an email to jj.prrs@palmettogba.com notifying us and indicating the specific claim identifiers (DCNs) and related documentation you are prepared to submit. If the documentation is NOT PHI/PII based, please proceed with attaching and submitting it with your email.
  • You may submit a request via the eServices online provider portal at www.palmettogba.com/eservices via the general inquiry form notifying us and indicating the specific claim identifier (DCNs) and you may include the related documentation even if it includes PHI/PII based information. 

The following are some examples (not exhaustive of all possible forms) of appropriate documentation:

  • Copy of the cancelled check if payment was already sent and processed for these identified overpayments
  • Credit Balance Report documentation showing the listing of claims you previously submitted with your report and requested to have cancelled
  • Proof of delivery receipt to Cahaba GBA 

The following are examples of submissions that have NOT  been granted an exception:

  • Providers who are no longer in business requested an exception for overpayments that occurred while they were in business
  • Providers identified claims as being paid by fee-for service Medicare as secondary which were determined to have processed as Medicare primary
  • Providers advised claims as processed appropriately under Medicare fee-for-service but for which a Medicare Advantage plan was determined to be in effect for those dates of service

8/28/2018: Delay in Claim Cancellation/Recoupment: During the delay in claim cancellation/recoupment, providers may take the following action with regard to their claims:

  • Providers who agree with the overpayments and wish to pay the money back to Medicare may proceed with cancelling claims
  • Providers who identify claims that were related to hospice but were billed without the 07 condition code on the claim, may proceed with reprocessing these with the 07 condition code along with the following remarks in the remarks section of the claim - MA Overpayment Timely Filing Exception so that we may process these with an exception to timely filing for administrative error

8/3/2018: Delay in Claim Cancellation/Recoupment:  Palmetto GBA and CMS have received a number of inquiries from providers and their representatives concerning provider appeal rights as well as information on how impacted providers may re-bill responsible MA plans.  CMS is working to address these concerns and provide information to MA plans that will help them be better able to identify any rebilled claims from providers.  So as to afford the agency with the time needed to develop complete guidance on these topics, CMS has requested that Palmetto GBA indefinitely delay its’ plans to auto-cancel claims for providers who have not submitted a valid exception request by August 17th. Additional information will be forthcoming in the next few weeks.

7/18/2018: The Status/Location S MOSU7 is assigned to all potential claims impacted by the MA Plan Overpayment issue. Affected claims will remain suspended until a valid exception is determined and/or the auto cancellation and recoupment process is initiated. No provider action is necessary.

07/10/2018: Postponement of Claim Cancellation/Recoupment: Providers who have exceptions they feel are warranted must at least start the exception process by submitting an INITIAL exception request no later than close of business on August 17, 2018. Receipt of an INITIAL exception request – with documentation – will result in a postponement of recoupment of ALL claims for which recoupment is sought until a determination is made of the legitimacy of the challenged claims. Even if you are unable to complete your review of ALL claims prior to August 17, recoupment will be stopped for ALL claims upon receipt of a valid INITIAL exception request. Palmetto GBA will begin the auto-cancellation of affected claims for providers who did not submit a valid INITIAL exception request on August 18, 2018.

6/12/2018: Providers with claims subject to the above reopening will receive a letter dated June 15, 2018 and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan.

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