There are potential civil monetary penalties for violating the Medicare limiting charge. The limiting charge applies to non-participating providers in the Medicare Part B program when they do not accept assignment and the beneficiary is not responsible for any billed amounts in excess of the limiting charge for a covered service.

If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.

Cancel the original claim and submit the claim to the VA. Once the canceled claim has processed, the Fiscal Intermediary Standard System (FISS) will automatically recoup the money you were paid.

Where the VA authorized services, Medicare does not make payment for items or services furnished by a non-Federal provider pursuant to such an authorization. Although certain MSP billing procedures apply, VA is not an MSP provision.

Reference

A post-payment review is conducted on services / claims that have already been submitted and paid by Medicare to the provider. First Coast is required to review documentation that substantiates information reported on claims submitted for reimbursement. We do this to ensure that the Medicare program reimburses only for covered, medically necessary, items or services furnished to eligible beneficiaries by qualified providers or suppliers.

Upon completion of the TPE review, a summary letter will be mailed to you detailing the outcome of the review as well as individual claim review determinations. The summary letter will also request that you set up a one-on-one educational call with the nurse who reviewed the case to ensure your understanding of the results, how they were determined and, if applicable, how to improve the outcome for future medical reviews.

An Extended Repayment Schedule (ERS) can be requested if the debt cannot be paid in full. Follow instructions outlined in the Sole proprietor or Corporation/group ERS forms below and return the required documentation.  Once a completed ERS has been received, a 30 percent withholding of claim payments will begin, and the withholding will continue until the review has been completed. The original documents must be mailed with the payment.

CMS clarified in the Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule that Medicare covers partial hospitalization program (PHP) services for the treatment of substance use disorders (SUDs).

LCDs and articles can be found by using the First Coast interactive LCD index.

In addition to using the interactive LCD index, First Coast’s LCDs and articles are available using the CMS Medicare Coverage Database. NCDs can also be found on the Medicare Coverage Database.