Amerigroup has begun conducting post-payment reviews of certain claims billed with modifiers for distinct procedural services. The reviews apply only to Medicare Advantage and Medicare supplement professional claims.
The reviews are in line with Amerigroup’s policy on distinct procedural services modifiers, which says it “reserves the right” to conduct reviews.
In an online announcement, Amerigroup said it may contact physicians with outlying billing practices to request additional documentation related to the services. If it identifies billing discrepancies, the payer will send the physician a written report of findings and recoup payment as appropriate.
“Medicare Advantage (MA) and supplement plans are allowed to go back as far as they want in performing post-payment reviews and recouping, unlike fully insured plans that only allow 180 days,” said TMA Payment Specialist Mary Fox. “Although MA plans have no timeframe, contracted physicians should still defer to their contracts, which might indicate a specified timeframe. The contract language would supersede.”
Amerigroup follows the Centers for Medicare & Medicaid Services guidelines for modifiers for distinct procedural services (modifier 59 and its subsets, XE, XP, XS, and XU), as explained in the National Correct Coding Initiative Policy Manual. (The section pertaining to modifier 59 is in Chapter 1, pages I-22 through I-26.)
The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.
If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
Last Updated On
May 30, 2018
Originally Published On
May 24, 2018