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February 3, 2016

“I’m just an employee. I have nothing to do with coding or billing.”

The Program Integrity Manual (IOM Publication 100-8, Chapter 3) provides Medicare Administrative Contractors instruction for conducting Error Validation Reviews, also known as Progressive Corrective Action (PCA) reviews.

When requesting medical records for PCA Review, or providing review results, the CGS Medical Review Department frequently receives the following responses from providers.

  • I can’t help you. I don’t code or bill, please contact the Billing Department.
  • Coding and billing is outsourced to another company.  I have nothing to do with the coding or billing of the services I provide to my patients.
  • I’m an hourly employee and have no part of coding or billing.
  • I only provide patient care and document the medical record.  I do not know, and have no control over what ultimately gets billed to Medicare.

While CGS recognizes the various egis under which providers practice, it is important for each individual provider to recognize they are ultimately responsible for the services submitted on their behalf for Program reimbursement.

CGS recommends providers:

  • Keep themselves educated regarding Medicare rules and regulations.
  • Ensure the services billed on their behalf for Program reimbursement adhere to the Medicare rules and regulations.
  • Maintain awareness of the manner in which the services they preform are billed.
  • Open and maintain a dialogue with those billing on their behalf.

During PCA, education through provider notification and feedback occurs when errors are identified. Additional corrective actions may be implemented based on the error rate, level of risk to the Program, etc.

Per 42 C.F.R. §424.535, CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges and any corresponding provider agreement based on a pattern or practice of submitting claims that fail to meet Medicare requirements. Should providers continue to fail to meet requirements, billing privileges may be revoked on this basis or any of the bases articulated in 42 C.F.R. §424.535(a).

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