CMS Publishes MLN Supplement on the Recoupment Process

The Center for Medicare and Medicaid Services (CMS) recently published a new Medicare Learning Network piece on the collection and recoupment process entitled “The Medicare Collection Process“.  I have posted a copy of this flyer on my website because I think this is an vitally important piece of information, especially for Texas Ambulance Suppliers.  Right now the Zone Program Integrity Contractor (Health Integrity, LLC) and Recovery Audit Contractor (Connolly Consulting Associates, Inc.) are quite active, especially in the non-emergency private ambulance business.

As I have blogged about numerous times, Trailblazer, the Medicare Administrative Contractor (MAC) for Texas, and CMS have been very active in Texas recently.  The estimates by Trailblazer that upwards of 90% of all transports of dialysis patients from the residence and upwards of 75% of transports of dialysis patients from nursing homes and skilled nursing facilities do not meet Medicare criteria for transport by an ambulance.

I don’t believe this is because these patients don’t benefit from the transport by ambulance, or from the regularity with which they receive dialysis because an ambulance company is keeping up with their dialysis schedule.  But in the current climate in healthcare, CMS is trying to decrease payments for fraud and abuse.  But they often cut awfully close to the bone, sometimes (often?) denying claims on patients who are fully qualified for services, but for other reasons such as poor documentation by the provider/supplier or such extremely narrow definition of what is allowed under the Medicare rules.

But this is the nature of healthcare in the new millennium.  If you don’t understand that, or don’t understand how to operate in this climate, then you need to learn how to do so immediately.  Compliance plans may currently be optional, but in the future they will not be optional and a well crafted compliance plan can help avoid problems with Medicare, Medicaid and third-party payors.  I am affiliated with Montgomery Healthcare Consultants, LLC (full disclosure: a part owner) and that company can help you craft a compliance program to meet your needs and monitor all aspects of compliance with state and federal law and industry standards.


Link to CMS Publication: “The Medicare Collection Process”

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