Medicare gives update on claim denials for incarcerated beneficiaries

Last year, the Centers for Medicare & Medicaid Services (CMS) refused to reimburse or ordered repayments from medical practices that had provided health services to beneficiaries the agency’s records showed were in prison on the date of service.

CMS officials later discovered that the information it used to determine whether patients were “in custody” or “incarcerated” was faulty, and the agency began making refunds.

Most of the refunds were made before the end of 2013. CMS sent to providers affected by the problem spreadsheets listing each claim for which a refund was paid.

Of course, not all of the repayment demands were determined to be invalid. Physicians who received repayment requests they believe were sent in error can ask their Medicare Administrative Contractor (MAC) to reopen the claim. Also, if a physician’s MAC provided a remittance advice (RA) indicating a temporary allowance (TA) but no other information, the physician can ask for an explanation from the MAC.

For more information on coverage and claims denials for services furnished to incarcerated Medicare beneficiaries, read this article and fact sheet from CMS.