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CIS Recoupments Begin – Still Time To Appeal

CIS Recoupment ClaimsThe first Special Remittance Advices (“RA”) pursuant to the Department of Community Health’s CIS Claims Reprocessing were issued this week.  Claims originally processed between November 1, 2010, through June 30, 2012, that billed specific CPT codes are subject to this special reprocessing based on the CMS National Correct Coding Initiative mandated by the Affordable Care Act.

Early reports are that the Special RA’s detailing the voided claims have been several hundred pages long with recoupments reported from $5000 to $100,000.

Some providers have indicated that DCH may be willing to enter into payment plans with providers to space-out the recoupment amount and that the Department may also allow denied claims to be re-billed with the proper CPT modifiers to allow for payment.

Section 202 of DCH’s Part I:  Policies and Procedures Manual requires that claims be received within six (6) months after the month in which service was rendered to be reimbursed unless certain exceptions are met.  It is unclear whether DCH considers the Special Reprocessing as meeting the exception requirements.  If it does not, then providers may be limited to six (6) months for re-billing claims.

If you think the Department’s determination of recoupment is incorrect, you can still appeal the determination as described in Part I of this article. It is extremely important that you satisfy all of the appeal requirements and meet all deadlines.  Failing to do so means that you waive your appeal rights and may not be able to challenge the DCH action.

If you’ve received notice that your practice is subject to the reprocessing recoupment and need help or if you need to appeal DCH’s decisions, Jeyaram & Associates can help. Contact DJ Jeyaram at or 678.325.3872.

Center for Medicaid & Medicare Services Shows Georgia Hospital Charges Vary

Center for Medicare & Medicaid ServicesA new study released by the Center for Medicaid and Medicare Services demonstrates that hospital charges for in-patient surgical and life threatening procedures vary greatly – including those in Georgia. The report looks at hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011. These DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges.

Discrepancies for in-patient services in Georgia include:

Joint replacement or reattaching a limb:

  • Saint Josephs: up to $28,000
  • Northside: on average $62,000
  • Grady: up to $85,000

Treatment of pneumonia or pleurisy:

  • Grady: up to $19,000
  • Atlanta Medical Center: up to $41,000
  • North Fulton Regional in Roswell: up to $55,000

Admissions and treatment for life threatening conditions such as heart failure and stroke:

  • DeKalb Medical Center: up to $15,000
  • Atlanta Medical Center: up to $40,000
  • North Fulton: up to $58,000

The Center for Medicaid and Medicare Services issued the report in response to President Obama’s efforts to make the country’s health care system more affordable and accountable. To review the Center’s findings in Excel, click here. 



Office of Inspector General’s 2013 Work Plan Increases Focus on Hospital Billing and the Affordable Care Act

Last month the Office of Inspector General (“OIG”) released its Work Plan for Fiscal Year 2013 (“FY 2013 Work Plan”).  The FY 2013 Work Plan focuses on many of the same areas as the prior year; however, there are two areas that received extra attention:  hospital billing and payment issues and implementation of the Affordable Care Act (“ACA”).

For Medicare purposes, the OIG has added new reviews including:

  • the efficiency of edits to identify hospital claims that were billed as discharges when they should have been billed as transfers
  • costs resulting from inpatient hospital claims for canceled surgical procedures
  • savings resulting from new payments for swing-bed services at critical access hospitals

One area of increasing focus in the Medicaid arena is prescription drugs.  In FY 2013, the OIG intends to explore alternative payment methods for home blood-glucose test strips.  The cost-saving means include rebates and competitive bidding, both of which have been successful at reducing net payment rates in some states.

Finally, the OIG will continue to monitor the ongoing implementation of the ACA.  Actions that the OIG intends to take in FY 2013 include the following:

  • reviewing compliance of home health agencies with the ACA requirement that physicians or other certain practitioners have face-to-face contact with beneficiaries
  • exploring cost savings associated with rental rather than purchase of power mobility devices
  • planning the frequency of on-site visits as part of the Medicare enrollment or re-enrollment process

As the OIG begins to implement its FY 2013 Work Plan, providers should continue to monitor what Medicare and Medicaid areas receive increased attention.  Additionally, providers should be proactive as the deadlines approach for implementation of parts of the ACA.

Georgia Department of Community Health Conservative with Medicaid Changes

The Georgia Department of Community Health has decided not to move forward with an overhaul of Georgia’s Medicaid program.  There are two main reasons for the change:  (1) the Supreme Court’s decision to uphold the Affordable Care Act and (2) the upcoming election.  The Supreme Court left the decision of whether to expand Medicaid up to the individual states, and Georgia’s governor has not made a definite decision about whether or not the state will move forward with expansion of Medicaid under the Affordable Care Act.  In addition, some political leaders are voicing their intent to repeal the Affordable Care Act.  According to the DCH news release, “[T]he department concluded that the current health care environment is so volatile that acting now with a full redesign would not serve the best interests of all Georgians.”

DCH’s decision to implement only small changes based on information it received from the redesign process seems prudent in light of the current state of federal healthcare reform.  Implementing a complete overhaul of the entire Medicaid system in Georgia without definitive knowledge of whether Georgia will expand Medicaid under the Affordable Care Act or whether the Affordable Care Act will be overturned could create substantial problems for the state on many levels.  One impact is financial – the Medicaid budget is already facing a deficit, and DCH would be in an unfavorable position if it prematurely overhauled Medicaid at unnecessary expense to the State.

One final important point to note about the announcement is that DCH said that a Medicaid overhaul will not occur “at this time”, which means it could still happen after the political turmoil settles down. Any future changes to Georgia’s Medicaid program will be detailed here.