Physicians managing center-based ESRD patients can be paid an MCP that covers most outpatient dialysis-related physician services provided to each Medicare beneficiary who is being treated for ESRD. , The MCP varies based on the beneficiary’s age and the number of visits during each calendar month in which the beneficiary receives ESRD-related services. Physicians report (to Medicare contractors) separate Current Procedural Terminology (CPT) codes based on the beneficiary’s age and whether they provide ESRD-related services to the beneficiary on one visit per month, two to three visits per month, or four or more visits per month. A physician who provides ESRD-related services to a beneficiary during one visit per month receives Medicare payment at a lower payment rate. A physician receives Medicare payment at a relatively higher payment rate when services are provided during two to three visits per month. To receive the highest payment amount, a physician has to provide services during at least four ESRD-related services’ visits per month. Physicians managing ESRD patients who dialyze at home are paid a single monthly rate based solely on the age of the beneficiary. Physicians must furnish at least one face-to-face patient visit per month for the home dialysis MCP service; however, Medicare contractors may waive the monthly face-to-face requirement on a case-by-case basis.
Open Recommendations
| Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
|---|---|---|---|---|---|
| 270624 | No | $0 | $0 | ||
| We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to recover the $291,813 from physicians for instances in which the same physicians reported more than one CPT code and received MCPs for monthly ESRD-related services provided to the same beneficiary for the same month of service (for claims that are within the 4-year reopening period) | |||||
| 270625 | No | $0 | $0 | ||
| We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to instruct the physicians to refund beneficiaries the $1,092,149 in beneficiary cost-sharing (deductible and coinsurance) amounts that may have been incorrectly collected from beneficiaries or from someone on their behalf | |||||
| 270626 | No | $0 | $0 | ||
| We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to review the 1,598 claims totaling $289,169 in MCPs for potentially duplicate claims and $74,563 in associated beneficiary cost sharing (deductible and coinsurance amounts) and determine which of the claims should have been denied as a duplicate claim for ESRD-related services and o recover the portion of any MCPs from the physicians for claims for duplicate services (that are within the 4-year reopening period), and o instruct the physicians to refund beneficiaries the portion of the deductible and coinsurance amounts that may have been incorrectly collected from beneficiaries or from someone on their behalf | |||||
| 270627 | No | $0 | $0 | ||
| We recommend that CMS based on the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines that this audit constitutes credible information of potential overpayments) so that the physicians can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation | |||||
| 270628 | No | $0 | $0 | ||
| We recommend that CMS • implement improved claims processing controls, including improved system edits, to prevent and detect overpayments of claims for duplicate services. | |||||
