What are three ways that unitedhealthcare works with cms

Payers challenged a 2014 CMS Overpayment Rule and won. Here’s what healthcare executives should know.

A federal judge sided with UnitedHealthcare and other payers in a case that challenged an Overpayment Rule adopted by CMS in 2014.

CMS implemented the rule to comply with the ACA, which introduced a new mandate that if a Medicare Advantage insurer identified an overpayment it was required to report the overpayment and return the overpayment amount to CMS within 60 days, says Richard L. Trembowicz, JD, associate principal, ECG Management Consultants, a healthcare consulting firm.

The Overpayment Rule defined an overpayment as a payment resulting from any diagnostic code that was inadequately documented in a patient’s medical chart and which a Medicare Advantage insurer should have determined through reasonable diligence that the claimed code was undocumented and, therefore, the insurer had received an overpayment.

“In effect, the 2014 Overpayment Rule required that all diagnoses submitted to support risk adjustment payments be 100% correct on review, and that reasonable diligence would be required to avoid a False Claims Act (FCA) charge if an overpayment was not returned within 60 days,” Trembowicz says. “Most insurers conduct a representative sample of medical chart documentation and coding practices to satisfy the reasonable diligence standard, but they do not review 100% of patient charts, creating a factual conundrum of how much of a proactive review is reasonable.”

Here are three other things MCOs should know about the September 7 ruling.

• The court addressed various reasons for finding that the Overpayment Rule was inequitable. The court concluded that CMS was imposing stricter requirements for reporting and identifying overpayments on Medicare Advantage payers than traditional Medicare regulations.

The Social Security Act requires “actuarial equivalence” between CMS payments made to Medicare Advantage payers and those made under traditional Medicare. The court stated that although payments for services under traditional Medicare and Medicare Advantage are set by the same methodology, the Overpayment Rule “systemically devalues payments” to Medicare Advantage payers, says Maria Garcia, JD, of counsel, Kozyak Tropin & Throckmorton.

The court found that CMS doesn’t have the legislative authority to apply more stringent standards to impose FCA consequences through regulations. The court reached this conclusion because the FCA imposes liability for knowingly submitting false claims for payment to the government, while the Overpayment Rule states that only reasonable diligence must be used to determine whether an overpayment from CMS has been received and therefore has to be returned, Garcia says.

“Simply put, the court found that the FCA’s and Overpayment Rule’s standards were inconsistent, yet imposed the same severity of penalties,” Garcia says. “The court agreed with UnitedHealthcare that Congress intended the FCA to punish and deter fraud, and to not punish an honest mistake or an incorrect claim submitted through mere negligence.”

  2.  The ruling is a significant win for insurance companies. At this point, the ruling likely nullifies the obligations imposed on Medicare Advantage payers to report overpayments as delineated in the Overpayment Rule, Garcia says. Furthermore, insurance companies may face lower costs when reporting to CMS.

Although this ruling only addressed Medicare Advantage plans, which are covered under Medicare Part C, it may also effect Medicare Part A and Medicare Part B overpayment rules and their validity because of the various similarities between the overpayment reporting requirements applicable to these other sections of the Social Security Act. “Medicare Advantage payers should be ready to assess potential changes and review internal procedures to comply with the developing CMS reporting requirements for possible overpayments,” Garcia says.

  3.  The ruling is not final. Because a DC Circuit Court made the ruling, it can be appealed to the U.S. Supreme Court. However, “CMS is unlikely to prevail and instead, CMS will likely adjust the rule to comply with the decision, most easily by recognizing the differences between Traditional Medicare and Medicare Advantage data in applying the concepts of overpayment to risk adjustment,” Trembowicz says.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.

Ambulatory EEG Monitoring – Medicare Advantage Policy Guideline

Last Published 11.01.2022

This policy addresses ambulatory electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.

Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1) – Medicare Advantage Policy Guideline

Last Published 04.01.2022

This policy addresses bariatric surgery procedures for the treatment of morbid obesity and comorbid conditions. Applicable Procedure Codes: 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215.

Biomarkers in Cardiovascular Risk Assessment – Medicare Advantage Policy Guideline

Last Published 11.01.2022

This policy addresses the use of biomarkers in cardiovascular (CV) risk assessment. Applicable Procedure Codes: 82172, 82610, 83090, 83695, 83698, 83700, 83701, 83704, 83719, 83721, 86141.

Blepharoplasty, Blepharoptosis, and Brow Lift – Medicare Advantage Policy Guideline

Last Published 06.01.2022

This policy addresses blepharoplasty, blepharoptosis, and lid reconstruction. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924.

Blood Product Molecular Antigen Typing – Medicare Advantage Policy Guideline

Last Published 03.01.2022

This policy addresses blood product molecular antigen typing. Applicable Procedure Codes: 0001U, 0084U, 0180U, 0181U, 0182U, 0183U, 184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0221U, 0222U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112.

Bone (Mineral) Density Studies (NCD 150.3) – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses bone mass measurement (BMM)/bone (mineral) density studies. Applicable Procedure Codes: 0508T, 0554T, 0555T, 0556T, 0557T, 0558T, 76977, 77078, 77080, 77081, 77085, 78350, 78351, G0130.

BRCA1 and BRCA2 Genetic Testing – Medicare Advantage Policy Guideline

Last Published 05.01.2022

This policy addresses BRCA1 and BRCA2 genetic testing for hereditary cancers. Applicable Procedure Codes: 0102U, 0103U, 0129U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81432, 81433.

Continuous Glucose Monitors – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses therapeutic continuous blood glucose monitoring (CGM) systems. Applicable Procedure Codes: 0446T, 0447T, 0448T, A4238, A9270, A9276, A9277, A9278, A9279, A9999, E1399, E2102, G0308, G0309, K0553, K0554.

Cytogenetic Studies (NCD 190.3) – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses the use of cytogenetic studies for the diagnosis or treatment of genetic disorders in a fetus, failure of sexual development, chronic myelogenous leukemia, acute leukemias (lymphoid, myeloid, and unclassified), and myelodysplasia. Applicable Procedure Codes: 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291.

Erythropoiesis Stimulating Agents (ESA) – Medicare Advantage Policy Guideline

Last Published 09.01.2022

This policy addresses the use of erythropoiesis stimulating agents (ESAs) and erythropoiesis stimulating agents (ESAs) in cancer and related neoplastic conditions for the treatment of anemia. Applicable Procedure Codes: J0881, J0882, J0885, J0887, J0888, J0890, Q4081, Q5105, Q5106.

Facet Joint Interventions for Pain Management – Medicare Advantage Policy Guideline

Last Published 07.01.2022

This policy addresses facet joint interventions used in pain management. Applicable Procedure Codes: 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64999.

Genetic Testing for Cardiovascular Disease – Medicare Advantage Policy Guideline

Last Published 05.01.2022

This policy addresses genetic testing for hereditary cardiovascular disease. Applicable Procedure Codes: 0119U, 0237U, 81161, 81410, 81411, 81413, 81414, 81415, 81416, 81417, 81439, 81442.

Genetic Testing for Lynch Syndrome – Medicare Advantage Policy Guideline

Last Published 05.01.2022

This policy addresses genetic testing guidelines for Lynch syndrome. Applicable Procedure Codes: 0101U, 0130U, 0158U, 0159U, 0160U, 0161U, 0162U, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81435, 81436, 88341, 88342.

Hemophilia Clotting Factors and Products – Medicare Advantage Policy Guideline

Last Published 11.01.2022

This policy addresses self-administered blood clotting factors and anti-inhibitor coagulant complex (AICC) for the treatment of hemophilia. Applicable Procedure Codes: J7170, J7175, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212.

Home Blood Glucose Monitors (NCD 40.2) – Medicare Advantage Policy Guideline

Last Published 07.01.2022

This policy addresses home blood glucose monitors. Applicable Procedure Codes: A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, A9270, A9275, E0607, E0620, E2100, E2101.

Hospital Beds (NCD 280.7) – Medicare Advantage Policy Guideline

Last Published 09.01.2022

This policy addresses hospital beds for patient home use. Applicable Procedure Codes: E0193, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271, E0272, E0273, E0274, E0280, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0305, E0310, E0315, E0316, E0328, E0329, E0910, E0911, E0912, E0940.

Implantable Automatic Defibrillators (NCD 20.4) – Medicare Advantage Policy Guideline

Last Published 11.01.2022

This policy addresses implantable automatic/cardioverter defibrillators. Applicable Procedure Codes: 33202, 33203, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33225, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448.

Intravenous Immune Globulin (IVIG) – Medicare Advantage Policy Guideline

Last Published 06.01.2022

This policy addresses intravenous immune globulin (IVIG). Applicable Procedure Codes: C0972, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, Q2052.

Long-Term Wearable Electrocardiographic Monitoring – Medicare Advantage Policy Guideline

Last Published 07.01.2022

This policy addresses attended electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95706, 95707, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95722, 95723, 95724, 95725, 95726, 95951, 95956.

Lucentis® – Medicare Advantage Policy Guideline

Last Published 09.01.2022

This policy addresses the use of Lucentis® (ranibizumab) for the treatment of macular degeneration and macular edema. Applicable Procedure Codes: C9093, J2778, Q5124.

Mobility Devices (Ambulatory) – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses ambulatory mobility devices, including canes, walkers, and crutches. Applicable Procedure Codes: A4635, A4636, A4637, A9270, A9900, E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0153, E0154, E0155, E0156, E0157, E0158, E0159, E1399.

Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing – Medicare Advantage Policy Guideline

Last Published 02.01.2022

This policy addresses Human Leukocyte Antigen (HLA) typing to assess compatibility of recipients and potential donors as a part of solid organ and hematopoietic stem cell/ bone marrow pre-transplant testing. Applicable Procedure Codes: 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383.

Ocular Telescope – Medicare Advantage Policy Guideline

Last Published 08.01.2022

This policy addresses intraocular telescope (implantable miniature telescope [IMT]) for treatment related to end-stage age-related macular degeneration. Applicable Procedure Codes: 0308T, C1840.

Percutaneous Coronary Interventions – Medicare Advantage Policy Guideline

Last Published 11.01.2022

This policy addresses percutaneous coronary intervention (PCI). Applicable Procedure Codes: 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944, 92973, 92974, 92975, 92978, 92979, 93571, 93572, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608.

Pharmacogenomics Testing – Medicare Advantage Policy Guideline

Last Published 03.01.2022

This policy addresses pharmacogenomics testing (PGx). Applicable Procedure Codes: 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0117U, 0173U, 0175U, 0286U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 81220, 81225, 81226, 81227, 81230, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81346, 81350, 81355.

Pneumatic Compression Devices (NCD 280.6) – Medicare Advantage Policy Guideline

Last Published 09.01.2022

This policy addresses pneumatic devices for the treatment of lymphedema and for chronic venous insufficiency with venous stasis ulcers. Applicable Procedure Codes: A4600, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.

Porcine Skin and Gradient Pressure Dressings (NCD 270.5) – Medicare Advantage Policy Guideline

Last Published 06.01.2022

This policy addresses porcine (pig) skin dressings and gradient pressure dressings. Applicable Procedure Codes: A2001, A2004, A2008, A2010, A2013, A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513, A6530, A6531, A6532, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, A6541, A6544, A6545, A6549, Q4102, Q4103, Q4118, Q4124, Q4130, Q4135, Q4136, Q4142, Q4166, Q4175, Q4195, Q4196, Q4197, Q4203.

Posturography – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Code: 92548.

Pressure Reducing Support Surfaces – Medicare Advantage Policy Guideline

Last Published 09.01.2022

This policy addresses the use of Group 1, Group 2, and Group 3 pressure reducing support surfaces for the care of pressure sores, also known as pressure ulcers. Applicable Procedure Codes: A4640, A9270, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0194, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373, E1399.

Sleep Testing for Obstructive Sleep Apnea (OSA) (NCD 240.4.1) – Medicare Advantage Policy Guideline

Last Published 10.01.2021

This policy addresses sleep testing for obstructive sleep apnea (OSA). Applicable Procedure Codes: 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.

Transcatheter Aortic Valve Replacement (TAVR) (NCD 20.32) – Medicare Advantage Policy Guideline

Last Published 10.01.2022

This policy addresses transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), for the treatment of aortic stenosis. Applicable Procedure Codes: 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369.

Transportation Services – Medicare Advantage Policy Guideline

Last Published 12.01.2021

This policy addresses transportation services, including emergency ambulance services (ground), non-emergency (scheduled) ambulance service (ground), emergency air ambulance transportation, and ambulance service to a physician's office.

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