Content Section
|
Medicare Information Resource
|
Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).
|
MIR-2007-2AB, February 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
|
Enhance the Multi-Carrier System (MCS) to Avoid Duplicate Payments When a Full Claim Adjustment is Performed
Provider Types Affected
Physicians and other providers who bill Medicare carriers or Part A/B Medicare Administrative contractors (A/B MACS) for services
Provider Action Needed
In CR5424, from which this article was taken, CMS announces the enhancement of the Multi-Carrier System (MCS). MCS is the system that Medicare carriers and A/B MACS use to process Part B claims for physician care and other outpatient services to avoid duplicate payments when performing a full claim adjustment. CR5424 rescinds and fully replaces CR 3878. This article is mainly for informational purposes.
Background
In the MCS system , when a claim is adjusted because of an overpayment, an accounts receivable (A/R) is created and a demand letter sent by the carrier or A/B MAC to the provider. When a claim is adjusted because of an underpayment, payment is automatically sent to the provider.
If the claim adjustment (that created the overpayment) later turns out to be incorrect, the carrier or A/B MAC must adjust the claim again. This could happen for many reasons. The two most common are: problems with the original overpayment identification and an appeal decision favorable to the provider. When the claim adjustment occurs a second time (to allow for correct history) the MCS system will automatically issue payment to the provider. In many cases, this second payment is duplicative. This then requires an offset from the provider to collect the duplicate payment.
The MCS System Maintainer has designed full claim adjustment to act as a full claim void and replace in accordance with the collective understanding of the requirements for HIPAA. This design was developed using a process that if an adjustment creates an overpayment, an accounts receivable is created and a subsequent adjustment assumes that the accounts receivable has either been recouped or will be recouped.
Example:
- A claim is processed and $100 is paid to the Provider.
- It is determined that there is an overpayment of $100.
- The claim is adjusted to show the denial (-$100) and an A/R for $100 is created.
- The claim payment total from the 1st adjustment is $0 = $100 - $100.
- The Accounts Receivable has not yet been collected and the Provider appeals.
- The appeal decision is in the Provider’s favor.
- A second adjustment is performed to show the claim as paid. (+ $100).
- The second adjustment calculates its payment based on the previous adjustment.
- Since the previous adjustment reads $0.00 (because the claim was denied) the second adjustment. calculated a payment of $100 to the Provider.
- The claim payment total from the second adjustment is $100 = $0 + $100.
- A $100 check is issued because MCS cannot suppress the check.
- Since the A/R was never collected, the Provider has been paid twice.
Medicare carriers and A/B MACs have, to date, used a manual system to avoid duplicate payments. But now, the MCS system will have the ability to suppress duplicate payments when a full claim adjustment is performed on a previous overpayment adjustment.
Additional Information
You can find the official instruction, CR5424, issued to your carrier or A/B MAC by visiting http://www.cms.hhs.gov/Transmittals/downloads/R260OTN.pdf  on the CMS Web site.
If you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip.
Flu Shot Reminder
It's Not Too Late to Get the Flu Shot. We are in the midst of flu season and a flu vaccine is still the best way to prevent infection and the complications associated with the flu. But re-vaccination is necessary each year because the flu viruses change each year. Encourage your Medicare patients who haven’t already done so to get their annual flu shot and don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. It’s Not Too Late! Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
MLN Matters Number: MM5424
Pub. 100-20, Transmittal# R260OTN, CR# 5424
Related CR Release Date: January 12, 2007
Effective Date: April 1, 2007
Implementation Date: April 2, 2007
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/  on the CMS Web site.
|
