NOPR Update: Medicare Advantage Plans Request Recoupment for Inappropriately Paid NOPR Claims Retroactive to April 3, 2009

April 25, 2011

It is our understanding that some Medicare Advantage (MA) plans have sought recoupment of payments to providers for FDG-PET scans performed as part of NOPR. NOPR has sought clarification on this issue from CMS. Providers with specific questions should contact their Medicare Administrative Contractor (MAC) and the Medicare Advantage Plan.

Effective April 3, 2009, NOPR claims for beneficiaries enrolled in MA plans should be billed to the Medicare contractors who will make payments on behalf of MA plans directly to providers of the PET scan, on a fee-for-service basis. See Publication 100-16 (Managed Care Manual), Chapter 8 (Payments to Medicare Advantage Organizations),Section 40.4.3 – Special Rules for the September 2000 NCD on Clinical Trials.

In addition, see Publication 100-16 (Managed Care Manual), Chapter 4 (Benefits and Beneficiary Protections), Section 10.2 – Basic Rule, and Section 10.25 – Clinical Trials

In the event that a NOPR claim was billed to a MA plan after April 3, 2009, and the MA plan paid the PET provider in error, the MA plan can recover payment from the provider.

If this situation arises, the PET provider is entitled to bill the MAC on a fee-for-service basis. Note that the timely filing period for both paper and electronic Medicare claims for services furnished on or after January 1, 2010, is 1 calendar year after the date of service. Claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010. Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010.(see http://www.cms.gov/MLNMattersArticles/downloads/MM6960.pdf )

The MAC is required to pay the PET provider for covered services, less coinsurance.