You are the administrator for a small, busy, primary care physician practice (the “Practice”). The Practice treats 60% Medicare/Medicaid patients, 35% private insurance, and 5% self-pay. The Practice also operates its own laboratory. The local CMS contractor has sent you a letter alleging that the Practice has been submitting claims for improperly coded patient office visits and for lab work that is not indicated. The labs mostly relate to drug screening of patients who are believed to be abusing or addicted to controlled substances (e.g., oxycodone). CMS alleges that the practice is improperly maximizing reimbursement by: (i) billing for medically unnecessary labwork, and (ii) claiming a higher level of service than what was actually provided to the patient.
The Practice has asked you to start drafting a repose letter. What might some of your arguments be to support your Practice’s approach? In thinking and drafting, consider medical necessity standards, the state of Medicare/Medicaid regulations, appropriate record documentation of office visits, patient improvement goals, medical liability concerns, standard of care concerns, and patient preferences. (100 words)
Answer the questions below in ½-1 page each. You may include all three responses on one document for submission, and please be sure to include the question that is being addressed. Use references from the course materials in your response, including outside sources when necessary, and be sure to cite appropriately using either APA of Bluebook formatting.
What is MedPAC, when was it created, and what role has it had in setting payment rates for physicians?
What is the Medicare Secondary Payer (MSP) Program? Why was it created? What payment issues typically arise with MSP?
Medicare has seen a steady increase and reliance on non-physician practitioners (such as Nurse Practitioners and Physician Assistants) to treat patients. Research and explain how Medicare reimburses for their services. Do you think this switch to Physician Assistants and Nurse Practitioners is a positive or a negative? Explain.
(175 words)
