Now contractors are demanding providers pay back claims for the treatment of technically “incarcerated” prisoners – even though there’s no way the providers could have known the patients were prisoners.
 
Subscribers to our Part B listserv say they’ve gotten “demand letters” asking for their money back on claims that were paid on these patients from contractors Palmetto, NGS, WPS, and Novitas.
 
The wave of letters seems tied to an Informational Unsolicited Response (IUR) CMS activated in April (PDF) to catch claims made on prisoners. This was done in response to a recent OIG investigation that found CMS lost millions on care to prisoners between 2009 and 2011, and required CMS to do something about it.
 
According to a guidance document from NGS, which mirrors those of the other contractors, a patient may be” incarcerated” without being locked up 24/7 – “for example,” says the guidance, “a beneficiary who is on a supervised release, on medical furlough, residing in a halfway house, or other similar situation may, nevertheless, be in the custody of authorities under a penal statute. In such cases, Medicare payment may be barred.”
 
The document tells providers to first approach the patient in case his or her Social Security record of incarceration is incorrect. Apparently an ex-prisoner is supposed to “inform the SSA of his or her release from custody” so the record can be changed; if the ex-prisoner/patient has failed to do so, the contractors say the provider should “encourage the beneficiary to contact his or her local SSA office in order to have his or her records updated.” If satisfied that the patient is not a prisoner, the provider should contact the CMS regional office, says the guidance.
 
Why the patient should thus oblige the provider when he or she has already received treatment from them, the contractors don’t say. Also, there’s no obvious way for providers to find out the incarceration status of patients. “Don’t have a clue how to proceed since this is based on the SSN eligibility information,” says one listserv author.
 
We intend to explore this story further and follow up in a Part B News story.
 
Do you have any experience with this issue? Would you like to talk to us about it? Drop us a line and we’ll get in touch.