Academy Fights for Transparency in CMS Project

The Academy recently urged CMS to stand by its pledge for transparency and release edit criteria for its Medically Unlikely Edit, or MUE, project to the public.

At issue is CMS' refusal to disclose to physicians and other health care providers the MUE criteria CMS and its coding contractor, Correct Coding Solutions LLC, have developed and began using earlier this year. CMS has said it would not release the criteria for MUEs because physicians could use that knowledge to defraud Medicare by billing for more services than were actually required or provided.

CMS initiated its MUE project in 2006 as a means of detecting and denying inappropriate Medicare claims before payments are made to physicians and other health care providers. The first set of edit criteria was implemented in January 2007. A medically unlikely edit would limit the number of services for each CPT code reported and would prevent, for example, physician payment for removing ingrown toenails on 11 toes in a single patient visit.

In a Sept. 17 comment letter (2-page PDF; About PDFs) sent to Niles Rosen, M.D., medical director of CMS' contractor, Correct Coding Solutions LLC (with a copy to CMS), (then) AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky., cried foul. He said CMS' failure to release the edits to the general public was inconsistent with statements made in a previous CMS document on the MUE project, in which CMS stated that it wanted to "make this as public a process as possible." Fields asked how physicians could appeal decisions based on those edit criteria -- as CMS also suggested in that document -- when the criteria themselves are unknown.

He also pointed out that CMS had previously stated that typographical errors -- not intentional abuse of the system -- often were behind claim errors. Fields referred to the 2007 Improper Medicare Fee-for-Service Payments Report, which found there was only a 3.8 percent overpayment rate among all fee-for-service contractors.

"Despite this, physicians often find that they must work within a health care system which assumes ill intent on their part due to the egregious acts of a very limited number of physicians and providers," wrote Fields. The MUE situation affords CMS an opportunity to work collaboratively with physicians. "Transparency of coverage policies and edits is necessary for collaboration and mutual respect," he added.

Fields said releasing edit criteria to the public would in fact help reduce the Medicare paid claims error rate. With that information in hand, software vendors could build edit criteria into their practice management systems, which could then alert a physician's practice to problem claims before those claims were transmitted to Medicare.

Just a week after the Academy's letter was mailed, the AMA sent a similar comment letter to Rosen. The Sept. 25 letter was signed by the AMA, the AAFP and 63 other medical organizations, including the American Academy of Pediatrics, the American College of Cardiology, the American College of Physicians, the American Osteopathic Association and the Medical Group Management Association.