09/07/2023

CGS Sends Repayment Request Letters to Ohio Podiatrists

OHFAMA and APMA have been in touch with CGS regarding the recoupment letters many members have received in recent weeks.

The recoupment letters state providers are responsible for repayment based on one or both of the following criteria:

1. Provider billed and/or received payment for services for which you should have known you were not entitled to receive payment.
2. Provider received overpayments resulting from retroactive changes in the Medicare Physician Fee Schedule and/or changes mandated by legislation.

CGS reviewed several claims submitted by OHFAMA members but have not provided a comprehensive list of reasons why podiatrists are receiving takeback letters.

Dr. Andy Bhatia, the Ohio Carrier Advisory Committee (CAC) representative, noted many of the impacted claims are several years old rendering CGS customer service representatives unable to pull up some claims in their system.

“While it may be true some of the letters are due to changes in the fee schedule, members deserve to know what exact changes CGS is referring to in their correspondence,” said Dr. Bhatia. “I would advise members to appeal the denials for clarification for the exact reason for each takeback. If CGS can demonstrate the correct reason for each takeback during the appeals process, then members should pay the amount back as requested.” 

A CGS representative noted the ongoing Targeted Probe and Educate on nail debridement revealed widespread use of templated documentation. CGS reminds members pain needs to be quantitative (not just simply “pain”) and ambulation status needs to be qualitative.  Documentation needs to be specific to each patient and not just copied records that do not specifically describe the issues with individual patients.

Members who’ve received letters from CGS are encouraged to continue to forward them, along with redacted EOBs, to the OHFAMA office via email mmathy@ohfama.org or fax (614.457.3375).   

Place of Service
Some of the letters center on place of service “32” versus “31” codes for patients in nursing homes. Members who were paid rate for long-term nursing home facilities (32) are receiving letters if their patients were in a skilled nursing facility (31), a short-term care/rehabilitation facility. The CGS letters are requesting repayment for the difference in the two rates.

If you see patients in a nursing facility it is important to include the correct place of service on claim forms. Oftentimes, the same facility may care for patients under both stay types. The onus is then placed on the provider to determine the correct place of service for every patient.

Patients who are under a POS 32 stay are typically in the facility for long-term care. Patients who are under a POS 31 stay have typically been transferred to a skilled nursing facility within 30 days of discharge from a medically necessary inpatient hospital admission of at least three consecutive days. Skilled nursing facility stays do not typically last more than 100 days.

For more information, please review the place of service code set.