Georgia's Trusted Healthcare
& Medical Provider Attorneys

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 DJ@Jeylaw.com or 678.325.3872.

Healthcare Providers Could See an Increase in Centers for Medicare and Medicaid Services Audits

On June 2012, the Department of Justice (DOJ) issued a report from its study of Home and Community Based Services (HCBS) waiver programs.  Seven of 25 states reviewed were found to have systems that were lacking in their ability to provide quality care to waiver program recipients.  In addition, the study found that the Centers for Medicare and Medicaid Services (CMS) did not use all means available to monitor the states’ programs.  As a result, the DOJ recommended that CMS implement additional requirements to ensure quality care.

Going forward, states may see more involvement and oversight on the part of CMS in enforcing compliance with the requirements of the HCBS waiver programs.  The increased attention paid by CMS could mean more site visits, audits, and compliance initiatives aimed at providers.  As with any audit or proposed adverse action, it is always to the provider’s benefit to consult with an experienced healthcare attorney immediately upon receipt of notice of an upcoming audit, audit results or overpayment demand letters.  The attorneys at Jeyaram & Associates have in-depth audit experience and are available for consultation.