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CMS Open Payments (the Sunshine Act)

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Did you receive this email within the last few days?
7 Days Remain to Review Your Data Before it Goes Public
What does it mean and whom does it affect?
If you are a billing service, you may have received this on behalf of your providers.
As of the end of September, 2014, CMS will make public monies received by physicians and hospitals from manufacturers and group purchasing organizations. As an example; an orthopedist uses just one manufacturer’s prosthetic for hip replacements. The orthopedist has convinced the purchasing department of the hospital to only purchase from this one company. The manufacturer has paid the orthopedist a sum of money for making this arrangement. This will now be made public. An ophthalmologist writes a paper about a new technique for cataract surgery mentioning a certain manufacturer. Previously, the surgeon had to state that a payment had been made by the manufacturer. Now, this information will be made public for anyone including the amount paid for the endorsement.
CMS has given all entities that will be affected by this new disclosure until September 11,2014 to review the information before it is released.
For more detailed information, check out the Open Payments User Guide
For more information about billing Medicare see our online course: Billing Medicare, TRICARE, and Medicaid

Chiropractic Maintenance Not Covered by Medicare

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Chiropractic Maintenance Therapy Not Covered


To meet Medicare coverage criteria, chiropractic treatment should be aimed at treating acute injuries, re-injuries, or exacerbations. The result of chiropractic manipulations is expected to be an achievable improvement and with a clearly defined end point. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered medically necessary under the Medicare program.

Maintenance therapy is defined by Medicare as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition. Therefore, Medicare does not cover maintenance therapy. For additional clarification of the coverage criteria for chiropractic services, refer to your MAC’s Local Medical Review Policy.


Medicare as Secondary Payer

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When a patient has Medicare and another health plan, it is necessary for the provider to make every attempt  to try to identify whether Medicare should be billed as the primary carrier. This is for all services rendered (or items delivered to a Medicare beneficiary.This can be done usually by contacting the MAC through their automated system or having the patient fill out a form such as this one:

If Medicare is not the primary payer, the provider must bill the other insurance payers before billing Medicare. The provider must submit a Medicare Secondary Payer (MSP) claim even if the primary payer made payment in full. This is done in case the “other plan” attempts to recoup monies from the provider at a later date. It would show timely billing to Medicare so that Medicare would possibly pay in case the other monies had to be returned at a later date.

When a Medicare beneficiary’s insurance has changed, it is up to the beneficiary to contact Medicare so that the changes can be made to the Medicare master file. Though the provider can attempt to update this information; the patient will be responsible for the bill if they have not assumed this responsibility, and followed up to make sure that the changes are reflected at Medicare.

When is Medicare considered primary or secondary?

The following link is an excellent (and updated) resource to help determine when a provider bills a health plan or Medicare as primary or secondary.


When submitting an MSP claim, the following fields MUST be filled out:

Item 4: If insurance primary to Medicare, list name of insured. When insured and patient are the same, enter “SAME”

Item 6: Check appropriate box for patient’s relationship to insured

Item 7: Enter insured’s address and telephone number. When address is the same as patient’s, enter “SAME”

Item 10a: Is patient’s condition related to employment? Yes/No

Item 10b: Is patient’s condition related to auto accident? Yes/No

If answer=yes, include the two digit state code under Place

Item 10c: Is patient’s condition related to other accident? Yes/No

Item 11: Enter insured’s policy or group number

Item 11a: Enter insured’s eight-digit birth date and sex if different from item 3

Item 11b: Enter employer’s name, if applicable

Item 11c: Enter nine digit payer ID for primary insurer or complete primary payer’s program/plan name

Conditional Payments

Under Medicare Secondary Payer law, Medicare does not pay for items or services that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers’ Compensation. Medicare may consider a conditional payment when there is evidence that the primary plan does not pay promptly, conditioned upon reimbursement back to Medicare when the primary plan does pay.

(This means that Medicare would have to be repaid if payment finally did come through from a Workers’ compensation or a no-fault liability insurer.) The Benefits Coordination & Recovery Center( BCRC) is the organization responsible for recovering conditional payments when there is a settlement, judgement, award or other payment made. When the BCRC has information concerning a potential recovery situation; it will identify the affected claims and begin recovery activities.


For more information on Medicare, please go to and look at the complete and updated courses available for medical billers.

*Please refer to the guidelines from your MAC as they frequently change and there are processes that one needs to go through to do this correctly.

** this article is not intended to be used as legal advice. If you are uncertain of any information in this article, we suggest that you seek legal counsel.

Handling Medicare Overpayment Letters

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Many Medicare Administrative Contractors or MACs are hiring outside Recovery Audit Contractors to audit claims in an attempt to recover Medicare funds that have been paid incorrectly or should not have been paid at all. In some cases these overpayments can add up to several thousand dollars. If overpayments are discovered a letter is sent to the provider informing them of the overpayment. It is important to know how to handle these letters when they arrive.


It can be very unnerving to receive a letter from your Medicare Administrator Contractor telling you that you need to repay $10,000 to your Medicare carrier because of overpayments over the past three years.

The overpayment may be for several reasons.

  • Duplicate submission of the same service or claim;
  • Payment to the incorrect payee;
  • Payment for excluded or medically unnecessary services; or
  • A pattern of furnishing and billing for excessive or non-covered services.

Before you panic, there are procedures that one must follow; including a strict timeline.



Day 1: you receive the letter from the MAC


Read the letter and the explanation as to how the overpayment occurred. If you do not understand why/how it occurred, call the MAC for an explanation. It is important that you understand why/how the overpayment occurred for two reasons:


  1. To determine if the overpayment is accurate
  2. To make sure it doesn’t continue going forward


Once you understand the reason for the overpayment, determine if you believe the overpayment is correct. One of the options described below is to submit a rebuttal. If you believe that the overpayment is not correct a rebuttal can be filed. For example, if you are notified that several claims for one particular patient were reprocessed because they state that the patient was incarcerated at the time of the services, but you know that the patient was not incarcerated, a rebuttal should be filed. Proof of the patient’s release from jail should be included in the rebuttal. Below the options of how you can respond are outlined:



Your options are:


  1. Make an immediate payment


  1. Request an immediate recoupment which means that your MAC will withhold a set amount of money, a percentage of future payments or take the complete amount owed from claims submitted.


  1. Request the standard recoupment process. If a full payment is not received 40 calendar days after the date of the initial demand letter, the standard recoupment process will begin on day 41. The overpayment will be recovered from current payments due or from future claims submitted.

If a debt has not been paid or recouped (unless a valid appeal has been filed) within 60 days of the date of the initial demand letter, an Intent to Refer letter will be sent indicating that the overpayment may be            eligible for referral to the Department of Treasury for offset or collection.


  1. Request an Electronic Repayment Schedule (ERS). If the practice cannot pay the overpayment in full, they can arrange to pay on a schedule but interest will be charged.


  1. Submit a rebuttal. You have within 15 days from the date that you received the demand letter to respond to your MAC. The letter needs to explain or provide evidence about why the MAC should not begin the recoupment. This rebuttal is not considered an appeal and will NOT stop the recoupment process however the MAC is required to address your rebuttal promptly.


Day 15: Last day for MAC to receive rebuttal


Day 30: MAC sends a second demand letter for delinquent overpayments. This is the last day to pay to avoid accrual of interest. It is also the last day to request an appeal and stop recoupment of overpayments. If you file an appeal after Day 30 but by Day 120, your MAC will stop recoupment when it receives and approves your appeal, but will not refund any monies already recouped.


Day 31: Interest begins to accrue for overpayments not paid to MAC in full by Day 30.


Days 61-150: MAC sends intent to refer (ITR) letter to the IRS for eligible delinquent debts.


Day 90: MAC attempts to contact practice by phone


Day 120: Last day to submit initial appeal request


Days 120-180: MAC enters the debt into the Debt Collection System to refer to the Treasury Department/ The MAC must attempt to reach the practice by phone at least seven days before referring to the DCS


The important thing is that you cannot simply ignore the demand for repayment. It will not go away. It is important that you determine if the overpayment is accurate and then take the appropriate action based on that determination. Making a plan will help to make the process easier.


* Please refer to the guidelines from your MAC as they frequently change and there are processes that you need to go through to do this correctly.


** This article is not intended as legal advice. If you are uncertain of anything contained in the overpayment request or any information in this article we suggest that you seek professional legal advice.


For more information on Billing Medicare visit our online course Billing Medicare, TRICARE And Medicaid