Filing Medicare High–Dollar Claims with WPS

by Joseph J. Muscato, MD, FACP, MOS President

I've heard from some of the MOS membership about your trials and tribulations with filing Medicare high-dollar claims with Wisconsin Physicians Service Insurance Corporation (WPS). As you know, the edits in the WPS system monitor claims that are approved for $5,000 or more, and WPS may review these high-dollar claims for any service. These reviews are expected to continue into the future. CMS will send a development letter; however as soon as a Medicare control number is assigned to the claim, you may send supporting information to WPS by fax at 608.223.7546.

In gathering information from around the state, it seems that some of the practices that are successfully getting reimbursed in a reasonable timeframe are faxing the following documentation to support each detail line of service on the claim:

• A copy of the development letter from CMS or
• The form from the CMS website
• A copy of the page from the package that contains the NDC information (page ONLY)
• Physician’s notes

Below are some very informative links from the WPS website that address the issues regarding high-dollar claims.

www.wpsmedicare.com/part_b/publications/2009_0629_highdollar.shtml

www.wpsmedicare.com/part_b/publications/2009_0831_highdollar.shtml

www.wpsmedicare.com/part_b/publications/2009_0831_basic.shtml

www.wpsmedicare.com/part_b/publications/highdollarfaq.pdf

There are several more good informative documents on the WPS website at www.wpsmedicare.com/part_b. A Medicare Outreach Staff will be putting together a presentation for MOS members.

Please continue to contact me or any of the MOS Board members as issues and questions arise, so that we can try to have WPS address them specifically and share solutions with the membership.

Thank you.

Dr. Muscato