A state of denial

Friday, October 31, 2003

SAN CARLOS, Calif. - Daryl Bowman can’t figure it out.

Over the past few months, CMS has rejected a handful of claims and recouped from him about $2,000. It seems Bowman, who owns Bowman Medical in San Carlos, Calif., billed Medicare for some capped-rental items even though his patients had entered a skilled nursing facility (SNF).

That’s a no-no.

Medicare doesn’t want to pay twice for the same item, and as part of their reimbursement, SNFs provide most capped-rental items. (Technically, a provider gets paid for the month if the patient enters the SNF after the monthly billing anniversary - the 15th of the month, for example. He won’t get paid if the patient enters prior to the anniversary.)

Thing is, until this year, Bowman had never experienced this kind of denial. Additionally, his denials have come flagged as N73 denials, which relates to a SNF’s responsibility to pay outside providers for furnishing urologicals and other supplies. It has nothing to do with capped-rental items.

“That’s my dilemma, Dr. Laura,” deadpanned Bowman.

Without seeing all the billing information, it’s tough to say what’s going on here.

One possible explanation: CMS has always balked at paying HME providers for capped-rental items if the patient enters a SNF. The DMERCs just didn’t police it all that well. But with budgets tightening, they’re looking more closely to recoup money they shouldn’t have paid out, said Bruce Brothis, president of Centralized Billing & Intake in Parker, Colo.

Another explanation: Region D DMERC, Cigna Healthcare, which covers California, may have recently turned on the edit that catches billing errors like the one confronting Bowman.

“The carriers turn edits on and off,” said billing expert Terri Maggio, vice president of Maggio Enterprises in Millville, N.Y. “If they turned on every edit for every claim, they would never get a claim through the system.”

Those explanations don’t cut it with DMERC ombudsman Doug Frazier, who claims neither is true. A more likely explanation, he said, is this: Because such denials have to line up with a patient’s billing anniversary, a potentially rare occurrence, Bowman’s rash of denials may be mere coincidence, Frazier said.

The N73 business, however, is puzzling, given Bowman’s explanation of what’s happening, Frazier admitted. But when it comes to SNFs and capped rental items, there’s nothing confusing: Medicare hasn’t and won’t pay a provider for a capped rental item if the patient enters a SNF.

Some say the provider can bill the patient directly when the patient enters a SNF. Frazier says they can’t. “It’s an oxymoron to put capped rental and SNF in the same sentence,” Frazier said. HME