CMS Starts Permitting Automatic Denials of Related Claims

On February 5th, the Centers for Medicare and Medicaid (CMS) issued Change Request (CR) 8425.  Effective March 6, 2014, CR 8425 will allow contractors to automatically deny claims that are related to other claims that have had non-coverage or non-payment decisions determined through medical review.

The Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs) will be permitted to deny payment of “related” claims without being required to request additional documentation. Examples of claims that could be considered related are:

• Physician claim related to an inpatient claim which was determined not to be reasonable and necessary through review.

• Professional component claim related to a diagnostic test claim which was determined not to be reasonable and necessary through review.

Home health and hospice providers may experience the most significant impact of this policy.  If an episode is denied because it does not meet Medicare payment criteria, all subsequent episodes may be automatically denied.

For more complete information, please follow this link to the CMS CR 8425: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R505PI.pdf

HC Healthcare Consulting staff includes certified coders, physicians, consultants certified in healthcare compliance and statisticians that are available to provide expert assistance with your Medicare and Medicaid compliance programs.

DISCLAIMER: This post contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link. Any advice or recommendations given is general and specific questions should be directed to professional counsel.

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