Providers can expect UPIN edits

Monday, December 31, 2001

WASHINGTON - On the heels of an OIG report that states in 1999 Medicare paid $32 million for medical equipment and supply claims with invalid UPINs and $59 million for claims with inactive numbers, CMS has released a program memorandum requesting carriers review claims and update UPINs.

Carriers are instructed to do so by April 1, 2002.

Neither the OIG nor CMS say whether providers used the wrong UPINs intentionally or that the equipment and supplies they billed for were not medically necessary. They do say, however, that the inability of Medicare to determine whether claims are submitted with the right UPINs creates the potential for fraud and abuse.

To mitigate that, the OIG study recommends CMS "revise claims processing edits to insure that UPINs listed on medical equipment and supply claims are valid and active." That'll likely happen once carriers have completed their review and update.

As a result, providers may see the following on their explanation of Medicare benefits (EOMB) in the future: reason code 52, the provider's not eligible to perform the service billed; and remark code M33, the claim lacks the UPIN of the physician or practitioner, or the UPIN is invalid.

Whether the edits will spell trouble for providers is unclear. Billing experts do have concerns.

They question how the carriers will handle equipment and supplies for which there is a lifetime need. If physicians no longer practice - regardless of the reason (i.e. license revoked, death, or retirement) - or if the patient changes physicians, that could be troublesome for providers.

"If the physician ordered it a year ago, and he goes out of practice, and it's a lifetime need, what does that have to do with medical necessity?" said Wayne Stanfield, president and CEO of the Halifax, Va.-based Westan HME Services. "Unless you're diligent about checking these things every month, you're not going to know."

And verifying UPINs isn't easy, according to Stanfield. He said the UPIN directory is typically months out of date, and the more up-to-date CD-ROM version is hard to use.

Most billing experts agree that the UPIN edits shouldn't pose problems for providers nationwide. Even the OIG report states that a small number of suppliers accounted for a significant share of the invalid and inactive UPINs. The report states that 100 providers accounted for $17 million of the $91 million paid for medical equipment and supply claims with the wrong UPINs. HME