American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to navigate the new rules on itemized statements

From the April 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: I heard that Medicare plans to notify beneficiaries that they can request an itemized list of the services furnished by their provider(s). How will that process work?

A: Section 4311 of the Balanced Budget Act of 1997 (BBA 97) gives Medicare beneficiaries the right to submit to their provider or supplier a written request for an itemized statement for any Medicare item or service. This provision was included in the BBA 97 to encourage beneficiaries to carefully review their medical bills and to enlist them in fighting fraud and abuse. (For more on HCFA's efforts to involve beneficiaries in catching fraud, see "Doctors object to enlisting patients in war on fraud," page 10.)

Medicare contractors issue beneficiaries an Explanation of Medicare Benefits (EOMB) or a Medicare Summary Notice (MSN) to inform them of Medicare's payment decisions regarding claims submitted on their behalf by their physician or other health care provider. HCFA recently instructed its contractors to include language on all EOMBs and MSNs informing beneficiaries of their right to request an itemized statement. Beginning April 1, most carriers will include the following language on EOMBs and MSNs:

"You (the beneficiary) have the right to request an itemized statement which details each Medicare item and service which you have received from your hospital, physician, or any other health care supplier or health professional. Please contact them directly if you would like an itemized statement."

Q:What should an itemized statement entail?

A: HCFA expects providers and suppliers to provide beneficiaries an itemized statement using their internal billing or accounting system. While the law does not specify what information should be included in an itemized statement, HCFA recommends that an itemized statement contain the following elements:

  • name of beneficiary;
  • date of service;
  • description of item(s) or service(s) furnished;
  • number of services furnished;
  • provider/supplier charges; and
  • an internal reference or tracking number.

HCFA notes that providers can include the following additional information if the claim has been adjudicated by Medicare: amounts paid by Medicare; beneficiary responsibility for co-insurance; and Medicare claim number.

HCFA also recommends that a response include the name and telephone number of a contact person so beneficiaries can call if they have any questions. You should not charge a beneficiary for an itemized statement.

Q: What is the process for handling beneficiary inquiries for an itemized statement?

A: HCFA envisions that this information will enable beneficiaries to reconcile an itemized statement with the corresponding EOMB or MSN. Contractors will direct beneficiaries with questions to the appropriate provider. The provider is expected to assist the beneficiary in understanding any discrepancies between the two documents.

Customer service representatives at Medicare carriers will attempt to resolve any questions by explaining applicable Medicare reimbursement rules.

Beneficiaries may ask their carrier to review a claim based on information contained in an itemized statement. Beneficiaries must submit requests to the carrier in writing and should identify the specific item(s) or service(s) that the beneficiary believes was not provided as claimed. Contractors may ask providers for help in examining the itemized statement as they review beneficiary complaints. When appropriate, carriers will seek to recover overpayments. The government can also impose penalties for cases involving true fraud.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to bbaker@acponline.org.

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