KAILUA-KONA — The Centers for Medicare and Medicaid Services continue to work with HMSA to look for trends that might suggest inappropriate coding and billing procedures after several people were improperly billed copayments for a procedure.
The federal agency said a provider “inappropriately coded” 10 prostate-specific antigen tests over a 12-month period.
Tom and Christine Russi said they discovered they had been improperly billed last July, “because we check anything we receive from HMSA, with a ‘fine toothed comb,’” they told West Hawaii Today.
The issue involves the prostate-specific antigen (PSA) test, which can carry a co-pay or not depending on whether it’s considered a screening or diagnostic test.
Under HMSA’s Medicare Advantage, there’s no copayment for a PSA screening, which is ordered if there’s no related diagnosis, said Jack Cheevers, public information officer at the Centers for Medicare and Medicaid Services. But a diagnostic test carries a $5 copayment, he said.
A provider would order the diagnostic test if a patient had been diagnosed or if the provider was seeking a diagnosis or looking to rule out or confirm conditions the test could identify.
Cheevers said in the Russis’ case the provider coded and billed the screening test as diagnostic.
That provider, he added, had also “inappropriately coded nine other tests as diagnostic” over a 12-month period.
He noted that not all of the remaining nine beneficiaries paid the $5 copayment after being charged, so the total impact was under $45 and HMSA reimbursed those who did pay.
“At this time, CMS is working with HMSA to analyze coding practices of its own contracted providers,” Cheevers said. “CMS will consider further actions depending upon the outcome of that review.”
HMSA also confirmed they were working with CMS to “remind providers about the proper procedures for correctly coding diagnostic and screening lab tests.”
At the end of April, Cheevers said CMS is continuing to work with HMSA to identify trends that “might indicate other inappropriate coding and billing” for the service among contracted providers.
Those enrolled in Medicare Advantage or Original Medicare who believe they might have been billed inappropriately for Medicare-covered services should contact 1-800-MEDICARE. Medicare Advantage members can also contact their plan directly, Cheevers added.