CMS recovery efforts on incarcerated patients confusing

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Recently, CMS initiated recoveries, prompted by an OIG report, from providers based on data that indicated that the beneficiary was incarcerated on the date of service (DOS). But, CMS has flip-flopped on its instruction leaving many confused about what to do. Medicare has identified previously paid claims that contain DOS that partially or fully overlap a period when the beneficiary was incarcerated based on information from the Social Security Administration (SSA). A large number of overpayments have been identified and demand letters released with appeal instructions. Initially CMS requested that providers not file an appeal request, but for some of those that followed that advice had the money recouped anyway. CMS' initial instruction also suggested that the provider contact the patient for addition information and to have them call their local SSA office about having their record amended, and should fax claim specifics to the local CMS office.

CMS now instructs, after learning it had received incomplete information from SSA, that you not ask your patient to contact the local SSA office and to no longer fax claim information to the CMS regional office. CMS further instructs providers to review its list of Frequently Asked Questions and to keep an eye on the CMS All-Fee-For Service Providers page for updates.

KMS staff is working with the AMA and the CMS staff in Baltimore to resolve the issue but in the meantime encourages you to appeal a recoupment demand.

Medicare will generally not pay for medical items and services furnished. A beneficiary may be "incarcerated" even when the individual is not confined within a penal facility, such as a beneficiary who is on a supervised release, on medical furlough, residing in a halfway house, or other similar situation. However, most physicians don't know the status of an incarcerated patient, unless they present in shackles and escorts. KMS, and other medical organizations have communicated this and that its recovery efforts are significantly flawed and urged the agency to stop the recovery and improve the process used to identify periods of incarceration.

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