Itemized statement push could affect practices
Here’s what needed and recommended
As part of its attempt to involve Medicare patients in identifying potential billing fraud and abuse, the Health Care Financing Adminis tration (HCFA) has started notifying beneficiaries they can request an itemized statement of medical services they have received from their physician to check for possible discrepancies.
The program has its basis in the Balanced Budget Act of 1997, which gives Medicare beneficiaries the right to submit written requests to their provider or supplier asking for an itemized statement for any Medicare item or service. This provision was included to encourage beneficiaries to carefully review their medical bills and to enlist them in fighting fraud and abuse, says Brett Baker, a third-party billing specialist with the American College of Physicians-American Society of Internal Medicine in Washington, DC.
The key elements
Baker says these are the key elements involved:
o Notice.
Medicare contractors will issue beneficiaries an Explanation of Medicare Benefits (EOMB) or a Medicare Summary Notice (MSN) to inform them of Medicare’s payment decisions regarding claims submitted on their behalf by their physician or other health care provider. HCFA recently instructed its contractors to include language on all EOMBs and MSNs informing beneficiaries of their right to request an itemized statement.
As of April 1, most carriers began including the following language on EOMBs and MSNs: "You (the beneficiary) have the right to request an itemized statement which details each Medicare item and service which you have received from your hospital, physician, or any other health care supplier or health professional. Please contact them directly if you would like an itemized statement."
o Content of itemized statement.
HCFA expects providers and suppliers to provide beneficiaries an itemized statement using their internal billing or accounting system. While the law does not specify what information should be included in an itemized statement, HCFA recommends they contain the following elements: name of beneficiary, date of service, description of item(s) or service(s) furnished, number of services furnished, provider/supplier charges, and an internal reference or tracking number.
HCFA also says providers can include the following additional information if the claim has been adjudicated by Medicare: amounts paid by Medicare, beneficiary responsibility for co-insurance, and Medicare claim number.
HCFA also recommends that responses include the name and telephone number of a contact person beneficiaries can call if they have any questions.
o Charges.
You should not charge a beneficiary for an itemized statement, Baker recommends.
o Inquiries.
HCFA says this information will enable beneficiaries to reconcile an itemized statement with the corresponding EOMB or MSN. Contractors will direct beneficiaries with questions to the appropriate provider. The provider is expected to assist the beneficiary in understanding any discrepancies between the two documents. Meanwhile, customer service representatives at Medicare carriers will attempt to resolve any questions by explaining applicable Medicare reimbursement rules.
Beneficiaries may ask their carrier to review a claim based on information contained in an itemized statement. Beneficiaries must submit requests to the carrier in writing and should identify the specific item(s) or service(s) the beneficiary believes was not provided as claimed.
Contractors may ask providers for help in examining the itemized statement as they review beneficiary complaints. When appropriate, carriers will seek to recover overpayments. The government also can impose penalties.
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