Carrier/Fiscal

Intermediary Documentation

Compliance Policy #911

Often times it is necessary to get advice from the Carrier or Fiscal Intermediary on a significant issue.  It is often necessary to ask the Carrier or Fiscal Intermediary for written confirmation of that advice.  It is the policy of the Hospital that the Hospital will request written documentation of a carrier's or intermediary's advice if the Hospital intends to rely on that advice.

The following is a model letter that should be used and sent to the Carrier or Fiscal Intermediary.  This letter may be sent via mail or may be sent via  e-mail.

EXAMPLE

November 1, 1999

(Insert recipient's name)
ABC Carrier or Fiscal Intermediary
P. O. Box 1234
Anytown, USA  00000

Re:  Medicare Billing Inquiry

Dear (Insert name),

On October 1, 1999, at 1:00 p.m. Jane Doe, Billing Manager of my office, had a telephone conversation with John Smith, (Insert Title), regarding a Medicare Billing question. 

As Miss Doe explained during the telephone conversation, the following situation arose:  (Insert relevant facts and circumstances that led to your question).

Since then, she asked Mr. Smith the following question:  (Insert the Medicare billing question discussed during the phone call). 

After discussing the question, facts, and circumstances, Mr. Smith advised us as follows:  (Insert a clear, accurate statement of the advice).

So that we may determine if it is reasonable to rely on this advice when submitting future Medicare Reimbursement Claims, we ask that you confirm this as ABC Carrier's or F.I.'s official advice so that we may fully understand your answer and minimize any future billing misunderstandings.  If there are any statutes, regulations, or written policies that are relevant to this question, we ask that you supply us with their citations so that we may review them.
If this letter accurately reflects your company's advice to us regarding our Medicare billing question, please sign the confirmation below and return this letter to me in the enclosed, self-addressed, stamped envelope.  A copy of
this letter is enclosed for your records.  (you may also send an e-mail to your Carrier or F.I.).

If we receive no response to this letter within 120 days, this office will assume that the oral instructions as set forth in this letter are correct and that it is reasonable for us to rely on the advice and act accordingly.  Thank
you for your cooperation in this matter.

Yours truly,


Mr. President, XYZ Hospital

(Page 2)

CONFIRMATION:   I hereby confirm that I have read the foregoing and that it accurately states ABC Carrier's or F.I.'s advice concerning the Medicare inquiry referred to in this letter.

Signature

Date

PROCEDURE
1. Send the copy to Carrier's or Intermediary's Medical Director, or their provider representative or liaison assigned to you.  Be sure to send a copy to the person who gave you the oral advice.
2. Retain a copy for your records and forward a copy to the Compliance Officer.
3. Make sure that the date and time of the conversation is noted on the letter.
4. Make sure the name of the person spoken to is on the letter.
5. If you are asking an isolated question dealing with one beneficiary claim, the memo you created for your file documenting your discussion with the carrier or intermediary should be adequate documentation.
6. If you are asking a question about a coding or billing practice, such as CPT code to use for a test you perform hundreds of time each week, make sure that you can prove you acted reasonably in relying on the oral advice.  This is the type of situation where you would want to follow up with a letter.

PURPOSE

Asking a Carrier or Intermediary to confirm oral advice in writing gives them an opportunity to correct mistakes and misunderstandings before the Hospital relies on the advice.  Carriers and Intermediaries will check advice very carefully before confirming it in writing.  The Carrier and Intermediaryshould be given 120 days from the date it receives the Hospital's request to respond.  If they have not responded by that time, the Hospital shall consider the oral advice appropriate and proceed to follow the oral advice.


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