As previously announced with notification of CMS CR 8165 (MM8165) Medicare implemented a common working file system edit to identify claims where more than one new patient visit was billed for the same patient within three years.
To assist providers with questions that they may have relative to these new guidelines, we are providing the below Q&A:
1. Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit?
Yes, if the service you actually performed was an established patient visit you can request a telephone reopening by calling 1-877-735-8073 for Jurisdiction L or 1-855-252-8782 for Jurisdiction H. You must tell us the specific established visit code you want us to change on your claim. There may still likely be an overpayment since established patient visits typically allow less than new patient visits.
2. I initially billed a claim with an established patient visit in error before I billed my claim for the initial visit. As a result I received an overpayment letter. Can I make corrections to both claims?
Yes, you can correct both claims by calling our telephone reopening line
3. Can I appeal my overpayment?
You certainly have the right to appeal any overpayment; however, your appeal will likely be affirmed since Medicare guidelines do not allow more than one new patient visit within 3 years. Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.
Note: Providers are encouraged to contact our telephone reopening line timely as recoupment action will occur.
If you do not have reason to appeal/request a telephone reopening and are in receipt of an overpayment related demand letter, please consider the option of making payment to Medicare using the immediate recoupment request process, as opposed to choosing to send in a check to Medicare. Requesting immediate recoupment is an efficient practice for both Medicare as well as the provider. Instructions for requesting immediate recoupment are outlined in Medicare Overpayments.
Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period. This guideline is outlined in the Internet Only Manual, Publication 100-04 Chapter 12 Section 30.6.7A.
In addition to this new edit, the Common Working File has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period. This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit.
As a result of these new edits, CMS has mandated that contractors request overpayments on any claims that were previously paid when either:
An established patient visit was billed prior to an initial visit within a three year period by the same rendering provider; or
More than one new patient visit was billed within a three year period by the same provider or different providers in the same group with the same specialty.
These new system edits were turned on October 1. A large number of paid claims have been identified as overpayments due to the above guidelines and as a result, Novitas Solutions has initiated recoupment of improper payments related to these claims. The impacted providers will be receiving an overpayment letter soon.