6.1.16   On March 14, 2016, new Medicare legislation called the 60 Day Final Rule went into effect that directly impacts our clinics and doctors.  The law concerns refunding Medicare money when the clinic realizes that Medicare overpaid on an account.  Please note that this new legislation does not change the existing process when Medicare realizes that they’ve overpaid and issues a Demand Letter, but rather addresses those instances in which the clinic discovers the overpayment before Medicare.  The new law requires offices to return any overpayment, regardless of the amount, within 60 days.  There are now serious fines for failure to comply, as well as the possibility of prosecution for fraud under the False Claims Act.  It should be noted that the law only applies to traditional Medicare, not Medicare Advantage plans, Medicaid, or commercial carriers.

Actually, Medicare has required providers to return overpayments within the 60 day window for the last six years.  What has changed with the new legislation, however, is RESPONSIBILITY, ACCOUNTABILITY, AND CONSEQUENCES!   The new law says that it is the provider’s responsibility to identify and return Medicare overpayments.  Medicare now holds their providers accountable to “reasonable diligence.”   In other words, lack of knowledge, training, poor business processes, or carelessness is not a protection from prosecution.  The bottom line is this:  If you didn’t know there was an overpayment but you should have known under standard business practices, you are guilty under the law.  Careless business operations such as failure to post remits and reconcile accounts or putting an insurance credits aside to investigate later is no longer acceptable.  In fact, the law actually says Medicare will not allow an “Ostrich Defense.”   Not realizing Medicare overpaid or ignoring overpayments is open to the same prosecution as deliberate fraud.

It doesn’t matter how small the amount of the overpayment–from 32 cents to $320 dollars, we are now required to return every penny in overpayments, and we have 60 days to get the money back in Medicare’s hands.  One piece of good news, however, is the effective date is not retroactive.  The 60 Day Final Rule begins with overpayments which are identified on or after March 14, 2016, so practices are not required to do internal audits to find older overpayments.

The 60 Day Final Rule even addresses third-party billing companies like OBS.   Our doctors are responsible for OBS’s compliance and can be prosecuted for our failures in handling your Medicare overpayments correctly.  OBS is taking the new legislation seriously.  We have put into place processes to handle overpayments and have trained all staff members. 

Since you as the provider are responsible for the manner in which we handle your accounts, we want to outline the process by which we will be managing your Medicare overpayments:

1. When an OBS biller identifies an overpayment and realizes Medicare is due back money, the biller will send the credit to a manager for review to ensure it is accurate.
2. Once the manager confirms the money is due back to Medicare, OBS will fill out a Voluntary Refund form for your Medicare jurisdiction.
3. We will attach the completed form to the Information Requested page on your Team Site. (You will need to open the IRS entry in Edit Mode to download the form.)
4. Please review the form, sign, and mail it to Medicare along with a refund check for the amount shown.
5. Post the refund on the patient’s account to off-set the credit and send the IRS entry back to OBS along with the check number so we can document the account.

Please know that OBS is doing everything we can to meet the requirements of the new law.  Together we can exercise “reasonable diligence” and ensure that your practice is not at risk!

UPDATE: 

THIS EARLY BLOG HAS BEEN EXPANDED IN A MORE RECENT POST WITH A MUCH MORE COMPLETE DISCUSSION OF CODING EXAMS MEDICAL OR ROUTINE, AS WELL AS IMPLICATIONS FOR BILLING AND INCREASED PRACTICE REVENUE.  CLICK HERE.

When it comes to insurance billing, optometrists live in a unique world where they are forced to juggle both routine and medical insurances, and this duality of payers causes frequent confusion for both doctors and patients.  Over and over again we hear doctors ask, “When patients have both medical and routine insurance, who am I supposed to bill the office visit to?”

Over the years, we’ve heard all sorts of answers to this question.  In fact, if you ask a panel of experts, you are likely to get as many different answers as there are people on the panel.   Doctors who are seeking clarification on medical vs routine billing might be surprised to find a very good resource on this subject published by the largest routine payer in the industry, Vision Service Plan.  Per VSP’s policy manual, how you bill the exam is driven by the patient’s chief complaint. The chief complaint should be the primary diagnosis on the claim, and this determines whether you bill routine or medical.   For example, if patients present with no medical problems and report no medically-related symptoms and state the intent of their visit is to renew their glasses prescription, the exam is routine and should be filed to their routine carrier.  However, patients who come in because they have glaucoma or macular degeneration made the appointment to monitor their condition, and these exams are medical.  Here’s another important consideration:  Some patients’ medical insurance covers an annual routine eye exam.  What do you do in this case?  VSP guidelines say to bill the patient’s medical payer first and then coordinate with their routine plan. 

So if you are a VSP provider, VSP has given you some very helpful and fair guidelines to assist you in deciding whether to bill office visits as routine or medical.  Per their policy manual, you only bill VSP if the patient has no medical chief complaint and the patient’s medical plan does not cover an annual routine eye examination.  That’s pretty straightforward and serves as a good rule of thumb for doctors when trying to traverse the confusing world of medical vs routine.

The key to any successful billing strategy is understanding your options and obligations, solid documentation in your chart records, and excellent patient education and communication.