Here’s a quick quiz. Imagine that a National Coverage Determination (NCD) lists six conditions for which a treatment is covered. During a review you find dozens of patients who received the treatment for a seventh, unlisted condition. Which of the following is true?
In a recent poll of Monitor Mondays listeners, only 22 percent of respondents chose e), which is the best answer. Let’s look at why, and why so few people chose it.
The first answer, a) is the most clearly incorrect. An NCD only applies to Medicare patients. Therefore, the assertion that you must refund every patient is completely inaccurate.
Private insurers can adopt Medicare rules, but they do not automatically apply. If you have a contract with a private insurer, and that contract incorporates Medicare policy, then you must likely follow Medicare policy. But absent a contract, or if the contract does not incorporate Medicare rules, Medicare policy is irrelevant. Even Medicaid doesn’t automatically follow Medicare rules. While Medicaid is a combination of a state and federal program, the coverage rules are generally determined at the state level.
The second answer is closer to being correct, but there’s a trap, and this is where a deep understanding of Medicare rules is important. The forward to the Medicare NCD Manual includes the following statement:
“Where coverage of an item/service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item/service is not mentioned at all in the Centers for Medicare & Medicaid Services (CMS) NCD Manual, the Medicare Administrative Contractor (MAC) has the discretion to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings, and general program instructions.”
Under this text, unless the NCD explicitly excludes coverage, the coverage is determined by the contractor. In other words, it has to be proper to bill the service, because absent a bill, the contractor can’t make a determination. (Some might argue “wait, you could ask the contractor without submitting a claim,” but that would not result in a “determination” under Medicare law. There would be no ability to appeal from the contractor’s review unless that review was a determination under the Medicare program.)
In the question above, the NCD lists six situations in which the treatment is covered, but it does not specify that other situations are uncovered. While there is a widespread belief among contractors, compliance professionals, and even healthcare attorneys that only the specified conditions are covered, that conclusion is explicitly contradicted by the Manual language quoted above.
If b) were correct, c) would also be true (or at least, close to true). You would have 60 days from the date that you quantify the overpayment to make a refund. The preamble to the 60-day rule makes it clear that you are permitted time to review the situation and quantify the overpayment before the clock starts. The preamble suggests that six months will generally be a reasonable amount of time. Once the overpayment is quantified, you then would have 60 days to make a payment.
The fourth answer, d) suggests that a refund isn’t required, but you may not bill for new patients. The first half of the answer is correct, but the second is wrong. When a Medicare rule is ambiguous, I often conclude that there is not an overpayment because the law is unclear. In an ambiguous situation, I may recommend that the client refrain from billing, but that is an option, not a requirement. It is a risk management decision, not a legal requirement. If you conclude that it is improper to bill going forward, barring a change in the law, you should also be refunding for past services. Only when the decision not to bill is optional can you refrain from giving a refund. That is why the final answer, e), is the best. A refund is not required, and you may (but need not) opt to bill going forward.
This is another example of the importance of carefully reviewing all Medicare policy, and of leveraging healthcare counsel that is not too quick to require a refund. When an organization provides medically necessary services to a patient, it is reasonable for the organization to receive payment for that care. The good news is that the rules, regulations, and policies of the Medicare program recognize this point.
As long as you fully understand them, you can avoid needlessly refunding money for the medical care you appropriately provided.
Imagine receiving notice that your healthcare organization faces a potential multimillion-dollar repayment demand based on the review of just 100 claims. This scenario, playing out
In the ever-evolving world of Medicare audits, 2025 is shaping up to be a year of Alice’s Wonderland. Enter stage right: artificial intelligence (AI), a
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
