Providers get a break on offsets

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Thursday, September 30, 2004

WASHINGTON - During all the industry uproar regarding HME reimbursement cuts contained in the Medicare Modernization Act, a component of the law that can actually help a provider’s cash flow has come into play more and more.

According to language in the MMA: If DMERC officials determine a provider has received an overpayment and the provider requests an appeal of that decision in writing, the carrier can’t recoup the overpayment until the appeal is concluded and a decision rendered.

“There really is no reason anymore for a healthcare provider to be squeezed for cash because Medicare claims refunds are owed,” said Kelly Pickens, an attorney with the Health Law Center in Greenville, S.C. “Now payment disputes may be fought on the merits, without regard to Medicare’s deep, deep pockets.”

Prior to passage of the MMA in December 2003, offsets began 30 days after the DMERC notified the supplier of the overpayment. The offsets didn’t stop until the provider won the appeal or paid back all the money. The abrupt interruption of cash flow often produced pernicious results, driving the provider deep into debt and sometimes out of business.

Providers still have just 180 days to appeal an alleged overpayment. Under the MMA, however, they are considered innocent until proven guilty. As long as the provider requests an appeal in writing within that first 30 days, the DMERC can’t begin offsets until after the fair hearing, provided it wins at the hearing. If a provider requests an appeal after the first 30 days but before the 180th day, the DMERC must cease the offsets until after the hearing.

That said, it can require a little arm twisting to convince DMERC officials to comply with the new law, said Denise Fletcher, a healthcare attorney with Brown & Fortunato in Amarillo, Texas. That’s because even though the new law is in effect, CMS has yet to a write regulation explaining it to the DMERCs.

“The DMERCs have not known how to implement it and have ignored the Medicare reform act and been offsetting,” Fletcher said. “We’ve had to call the DMERCs on occasion and say, ‘You can’t do that.’”

In one instance, Fletcher enlisted the help of an HME client’s congressman and senator to force a DMERC to stop offsetting.

“It’s funny,” Fletcher said. “Senators get really angry when you ignore laws they created.”

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