decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 2 (February)
Follow carrier's advice - even if it differs from Medicare audit contractor
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Article Overview
This article discusses Medicare Part B billing and audit response when a Recovery Audit Contractor or other Medicare-contracted auditor disagrees with a carrier’s guidance. It is aimed at physicians, billing staff, and compliance personnel who handle appeals, claim adjustments, and documentation support for disputed claims. The piece focuses on the general process for responding to audit demands, the role of carrier guidance, and the importance of written documentation.
Why This Topic Matters
Provider organizations can face conflicting instructions from different Medicare entities, so understanding where to direct appeals and how to preserve supporting documentation affects cash flow, compliance, and recovery of withheld payments.
Article Sections
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Carrier guidance versus Medicare audit contractor findings
Explains the situation in which audit contractor determinations appear to conflict with existing carrier billing guidance. The section frames why the issue matters for ongoing claim handling and appeals.
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Examples involving colonoscopy audits
Summarizes audit activity involving colonoscopy claims and the use of separate billing documentation. The section discusses how practices responded through carrier-directed appeals.
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Questions about future billing and claim appeals
Raises the broader operational questions providers may face when contractor findings and carrier advice do not match. The section addresses the general uncertainty around pending appeals and future claims processing.
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CMS guidance on handling disputed claims
Covers CMS statements about following carrier billing guidance, not rebilling the disputed claim, and using the normal Medicare Part B appeals process. The section also notes how adjustments are handled if an appeal succeeds.
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Waiver of liability and written documentation
Describes the general protection discussed for providers who relied on incorrect written guidance. The section emphasizes the role of documentation in showing good-faith reliance.
What You Will Learn
- How Medicare Part B providers should generally respond when audit contractor findings conflict with carrier guidance
- What role carrier appeals play in disputed audit cases
- Why written documentation matters in supporting disputed billing positions
- How the waiver of liability concept is discussed in the context of Medicare claims guidance
Who Should Read This
- Physicians
- Billing managers
- Medical coders
- Practice administrators
- Compliance staff
- Revenue cycle staff
Codes Discussed
Modifiers Discussed
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