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Carriers Can't Punish You For Self-Disclosing Problems
But There's A Catch -- Don't go straight to the carriers if the problem looks serious


The Medicare Modernization Act contains one welcome provision that prevents your carrier from putting you on prepayment review if you come forward voluntarily to disclose a billing problem. Or does it?

But now the Centers for Medicare & Medicaid Services has carved out an exception to that rule which the carriers could drive an 18-wheeler through. If you self-disclose an improper business practice, "and the contractor determines that there is a sustained or high level of payment error," then the carrier can go ahead and put you on prepayment review anyway, according to Transmittal 100-08 (Change Request 3569).

Still, the change is better than nothing, says attorney Lester Perling with Broad & Cassell in Fort Lauderdale, FL. "The carriers previously had a totally free hand in putting a provider on prepayment review," he notes. Now, they have to show a sustained pattern of overpayment, which CMS fails to define.

Most likely if you come forward with a couple of overpayments worth $500, you're safe, but if you disclose that all of your evaluation & management visits have been upcoded two levels for the past year, you could be in for some review, Perling says.

Fortunately for providers, the carriers aren't fans of prepayment review, because they don't get paid any more money for doing it. And it's a lot of work to move a provider from electronic to paper claims and pay someone to sift through all of them, Perling notes.