Erroneous Guidance by NGS Could Pose Problems for Hospitals

Are MACs going rogue?

According to a webinar held last week, NGS, the Medicare Administrative Contractor (MAC), has taken the targeted probe-and-educate audits (TPE) to an area one would never expect: the proper completion and delivery of the Medicare Outpatient Observation Notice (MOON), the Centers for Medicare & Medicaid Services (CMS) mandated notice to observation patients.

“Now, at first glance, maybe that’s not so bad, since proper use of all of these required forms can be challenging, and having external review may help improve processes,” Ronald Hirsch, MD, vice president of R1 RCM, told Monitor Mondays listeners this week. “But then, as the webinar presenters described, NGS has decided that if the MOON is not completed properly or delivered within the proper time frame, all the observation hours should come off the claim, and the hospital won’t get the Observation Comprehensive APC (Ambulatory Payment Classification) payment.”

According to Hirsch, NGS seems to be saying that improper completion of a required form means a hospital doesn’t get paid for the care it provided. Hirsch told the Monitor Mondays audience that he has asked CMS for the regulatory authority that would allow such a practice. Hirsch wondered aloud if that action by NGS meant that if an Important Message from Medicare (IMM) is not delivered in timely fashion, you don’t get payment for that admission, either.

As RACmonitor has been reporting (here and here), the MACs have started widespread recoupments for admissions from 2016 to 2018, wherein the patient was discharged to home with no services, but ended up starting home care or going to another facility. Late last week, a hospital reported that it is having $620,000 recouped for 43 admissions. But what is startling is that for 21 of those, they agree the discharge code was wrong, but the length of stay was such that the payment would be the same either way. These hospitals are experiencing recoupment of the full payment, and they were not overpaid at all.

“If any claim error, even one that does not affect the payment amount, can now lead to a full recoupment, it would set a very dangerous precedent,” Hirsch said.

In another apparent MAC misadventure, Noridian published a bulletin on Jan. 22 about the transcatheter aortic valve replacement requirements, reminding providers that two cardiac surgeons must examine the patient to determine the appropriateness of the procedure. The problem is that this requirement was removed by CMS in June of last year, when a final decision memo was released.

Hirsch told RACmonitor that out of curiosity, he reviewed the coverage requirements for UnitedHealthcare Medicare Advantage patients, and found that their policy, released Sept. 11, 2019, also requires two cardiac surgeons.

“This is a violation of Medicare regulation outlined in the Medicare Managed Care Manual, Chapter 4, Section 10.2, which does not allow MA plans to impose restrictions that are not placed on traditional Medicare patients,” Hirsch said.

RACmonitor is dedicated to keeping its readers up to date on all regulatory issues, and will follow these misadventures and report back as warranted.

Programming Note: Listen to Dr. Ronald Hirsch every Monday on Monitor Mondays, 10-10:30 a.m. EST.