Duplicate Payment Detection for Cost Contracting HCPPs and

300 - Duplicate Payment Detection for Cost Contracting HCPPs and HMOs/CMPs (Rev. 63, 11-12-04) Several entities may have jurisdiction over the processing and payment of Part B bills for an HMO’s/CMP’s members. This could result in duplicate payments to either the physician, supplier, or to the enrollee. It is incumbent that HCPPs and HMOs/CMPs establish a system to preclude or detect duplicate payments. Regardless of the claims option selected, HMOs/CMPs are required to process all non- provider Part B bills, with some exceptions. These exceptions, as noted below, are processed by the carrier or intermediary: • Claims for services by an independent physical therapist; • Claims for outpatient blood transfusions; • Claims from physicians for dialysis and related services provided through an approved dialysis facility; • Claims for home health services received under cost reports beginning on or after January 1, 2005; and • Hospice care by Medicare participating hospices, except: a. Services of the enrollee’s attending physician if the physician is an employee or contractor of the organization and is not employed by or under contract to the member’s hospice; and b. Services not related to the treatment of, or a condition related to, the terminal condition. Duplicate payment detection is the responsibility of the HCPP or HMO/CMP, not the carrier. The HCPP or HMO/CMP should perform several duplicate check functions after it receives paid claims information. If the HCPP or HMO/CMP has not previously paid the claim, a copy of the claims information is filed in the beneficiary’s history file. If the duplicate payment check reveals that the HCPP or HMO/CMP has already paid for the services: • Contact the physician/supplier or enrollee to retrieve the overpayment; • Record any collections as credits on the cost report; • Notify CMS of unresolved overpayment situations; and • Do not return payment to the carrier.