On July 12, 2016, Noridian Healthcare Solutions announced a new policy on denial of related claims, termed “Cross Recovery.” Noridian purports that this policy will help it to fulfill its obligations to the Centers for Medicare and Medicaid Services (CMS) by assuring that all Medicare claims are for medically necessary and reasonable services. Whatever the motivation behind Cross Recovery is, it reawakens the specter of related claim denials for Medicare providers, and is a development which should be watched closely in the coming months.
Noridian’s new program comes in the wake of several previously released CMS transmittals regarding the denial of related claims. Though later rescinded, CMS originally introduced a policy which broadly allowed MACs to deny related claims when issuing an adverse determination of an original claim. After receiving feedback from the provider community regarding concerns about the policy, CMS narrowed the scope of “related claims” power to only Part B surgery claims via Transmittal 541. Transmittal 541 allowed for such Part B surgeon services to be recouped following a denial of a Part A inpatient surgical claim as not reasonable and necessary. However, since the issuing of Transmittal 541, MACs have only very rarely invoked their discretion to deny such Part B surgical claims on Transmittal 541 grounds. Noridian’s new Cross Recovery policy may change this trend, and it is yet to be seen whether other MACs will take the opportunity to expand their own related claim denials.
Noridian’s statement (as linked above) was very brief, but significant. The statement cites section 3.2.3(A.) of CMS’ Internet Only Manual 100-008 Chapter 3, which states in relevant part that “MAC[s] and ZPIC[s] have the discretion to deny other “related” claims submitted before or after the claim in question, subject to CMS approval [.]” Noridian announced that it has received such CMS approval to “Cross Recover” professional claims related to denied institutional facet injection services (CPT codes: 64493— 64495; 64635—64636).
While it is still unclear whether Noridian will request other Cross Recovery discretion from CMS, this is a significant development. Even for Medicare providers who have nothing to do with facet injections, and those that are outside of Noridian’s jurisdiction, related claim denials are something to take notice of. Noridian’s Cross Recoveries could expand to other MACs, and ultimately to other CPT codes. The reawakening of related claims denials will increase the number of negative determinations for providers, highlighting the importance of proactive compliance. And in a Medicare appeals system which is already severely overburdened, any influx of new appeals will contribute to the backlog of cases and extend the wait for providers and suppliers waiting for final determinations of their Medicare appeals.
For over 30 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, including compliance with federal healthcare regulations. If you or your healthcare entity have any questions about denials of related claims, or any other health care regulatory compliance questions, please contact an experienced healthcare attorney at (248) 544-0888, or via email at firstname.lastname@example.org. You may also subscribe to our health law blog by adding your email at the top right of this page.