CMS issued a flurry of transmittals in 2014 concerning auditors’ ability to deny claims based upon discretion. Transmittal 505 gave contractors the right to deny claims related in some capacity to another claim that was denied. After rescinding 505, CMS issued Transmittal 541 which allows contractors to deny a surgeon’s claim if the hospital’s inpatient surgery claim is denied for medical necessity.
Thus far, few contractor groups have exercised denial power granted under 541. But Noridian warned surgeons and hospitals it would implement cross recovery to examine related claims when issuing denials.
In a statement, Noridian said, “when medical review results in longstanding high error rates, the Medicare administrative contractor may request CMS approval to deny related claims submitted before or after the claim in question.”
Noridian operates in jurisdiction F, which includes Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming.
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