Medical Fee Review - Another lesson of "Strict Compliance"

Medical Fee Review Petitions are the subject of another reported opinion of the Commonwealth Court of Pennsylvania. On April 18, 2013 we reviewed the decision in Witkin regarding Insurer "downcoding" of TMR (therapeutic magnetic resonance) treatments.

Petolillo v. Bureau of Workers' Compensation Fee Review Hearing Office (Traveler's Ins. Co.)
_A.3d _ (Pa. Cmwlth. April 22, 2013) reports eleven (11) consolidated Medical Fee Review petitions filed by nine (9) different medical providers, all involving insurer downcoding of TMR "treatments".

The Commonwealth Court remanded all of these petitions for a hearing to consider the insurers' compliance with the downcoding procedures at Regulation 127.207.

Apparently, in the recent past, the Fee Review Hearing Officers (HO) have decided on several occasions (with the same providers) that the correct CPT code for reimbursement of TMR treatments would be 97032 with a reimbursement rate of $26.24 not the requested $3,298.00.

In subsequent petitions, the HO applied their prior decisions to the current petitions and ...
reached the same result!!!

These TMR providers continue to appeal these determinations.
The subject of their appeal is the application of these prior determinations, without a full hearing on the merits of the "new" petitions..

Well, the Commonwealth Court has reluctantly agreed and the providers are allowed another hearing, on the same issue, with the same arguments.  Why?

The Judges believe that the statute and regulation, as written, compel the right to a hearing.
The HO must first determine that the insurer complied with the downcoding procedures before applying the existing caselaw, as the providers would be entitled to full payment if the insurer failed to follow the procedures.

Procedures for Downcoding

As the insurer compliance with the downcoding procedure may be the difference between reimbursement to a provider of $26.24 per treatment versus  $3,298.00 per treatment, we should familiarize ourselves with these procedures.

Regulation 127.207 "Downcoding by Insurers"

(a) changes to a provider's codes by an insurer may be made if the following conditions are met:

(1) the provider has been notified in writing of the proposed changes and the reasons in support of the changes.

(2) the provider has been given an opportunity to discuss the proposed changes and support the original coding decisions.

(3) the insurer has sufficient information to make the changes.

(4) the changes are consistent with Medicare guidelines, the Act and this subchapter.

(b) for purposes of subsection (a)(1) the provider shall be given 10 days to respond to the notice of the proposed changes and the insurer must have written evidence of the date notice was sent to the provider.

(c) whenever the changes to a provider's billing codes are made, the insurer shall state the reasons why the provider's original codes were changed in the explanation of benefits (letter) required by section 127.209 (relating to explanation of benefits paid).

(d) if an insurer changes a provider's codes without strict compliance with subsections (a)-(c), the Bureau will resolve an Application for Fee Review filed under section 127.252 (relating to application for fee review - filing and service) in favor of the provider under section 127.254
(relating to downcoding disputes).

Practice Pointers:

1. As Medical Providers of TMR are litigating these petitions, prepare your correspondence and documents, in anticipation of litigation. This is true of review of the TMR treatments and other alternative care, such as "Vax D" and "H Wave" therapies.

2. Document your correpondence! Note the Regulations requires the Insurer to have evidence of the date notice was given to the provider.

3. Also you must document your position with reasons. Where there is no Medicare CPT code, provide your explanation and the selection of an alternative code.

When in doubt ... ask for help from your Legal Counsel and/or you Medical Bill Review vendor.