*** NO PHI ***
HI *memo to United Rheum MSO/excerpts*, … this entails at least 5 calendar years 2017-2021, more than one MAC where ours is Novitas, and therefore greatly over 5 U.S. states. Of the tens of millions of dollars short funded to Providers (thousands of dollars short per one claim in many cases, extrapolated out thru the U.S.A.), there is no basis for doubt that they have illegally retained some significant percent thereof, given that some practices don’t well integrated communication among billing & clinical staff. So in posting these EOMB’s, you’d very sadly expect some billing staff writing off the wrongly denied amounts over non-duplicated ‘duplicates’ on different lines per each of 3 possible NDC codes associated with the 80 / 200 / & 400 mg vials. This is the oldest such Email sent to Novitas’ critical inquiries unit. From 3/25/2021, I’ll sent the most recent one from a 3/8/2021 DOS, copied herein – below.

The short funding error in question cannot & will not occur when there is just one line item for this J code, such as, 1.) the use of 2 vials of 400 mg with no wastage, 2.) using 3 x 200’s or 4×80’s also with no wastage.
The ‘JW’ wastage coding entails a separate line item, & they are capable of calling the first line or the ‘JW’ line ‘duplicates’ though they totally warrant and require separate lines.

We are under RAC Cotiviti audit for 14 DOS’ (14 claims) of Actemra infusions. We’ll see what their findings are. In the U.S., we are not supposed to have one class of people with rights & no corresponding responsibility (CMS Medicare) and another class with responsibility & no corresponding rights (Providers). Equal protection under law, or Goose/Gander in lay terms. The matter at hand is forensic in nature; it could have been called a mistake for a few weeks or the first 50 times they did it.

Charted to Dr. Barbosa last year: “I’m not repeating a federal case w/ CMS HHS OIG hotline, but yet this goes on for 4 years or so and I consider it fraud/theft/embezzlement & racketeering. Extrapolate across 5 states’ operations to consider vast amounts withheld some never funded. Mp”
Thanks so much.
Best wishes,
Mark Post
then, … From: [email protected] <[email protected]>
Sent: Thursday, March 25, 2021 11:46 AM
To: Taylor S **Redacted/Novitas Critical Inquiries**
Subject: Actemra/tocilizumab J3262 claim processing issues (New)

Hello Mr. S **Redacted**,
Please review the following and delegate as needed. ICN 2821068530220 EOMB dated 03/23/2021, DOS 03/08/2021, Med is Actemra (tocilizumab), & cpt is J3262 per mg.

Remaining issues in this J code processing entail mainly the first Line Item of the claim. Phone/IVRS appeal not done.

1.) J3262, 200 Units from 1 vial of 200 mg, distinct NDC code for 200 mg vial, denied/ “OA-18” for exact duplicate, Novitas’ Error. $1,093.80 full Allowable to post for Provider.
2.) vs. other vial sizes, Lines 2 & 3 are from 80 mg vials. Line 2 ‘Used’, line 3 ‘JW’ wastage with both lines 2 & 3 paid O.K.
3.) Lines 4 – 8 are processed fine as expected.

We have audited our own coding & cannot find any errors on point or otherwise.
Thanks so much for your attention. Best wishes!
…Mark Post, Admin. For Leyka M. Barbosa, MD; North Texas Joint Care, P.A.

p.s. As noted:(scan cut of ICN pasted to Novitas)

01/14/2020 EOMB
Our Billing NPI *****8219
***********************************
From 3/25/2021:
Hello Mr. S **Redacted**,
Please review the following and delegate as needed. ICN 2821068530220 EOMB dated 03/23/2021, DOS 03/08/2021, Med is Actemra (tocilizumab), & cpt is J3262 per mg.

Remaining issues in this J code processing entail mainly the first Line Item of the claim. Phone/IVRS appeal not done.

1.) J3262, 200 Units from 1 vial of 200 mg, distinct NDC code for 200 mg vial, denied/ “OA-18”for exact duplicate, Novitas’ Error. $1,093.80 full Allowable to post for Provider.
2.) vs. other vial sizes, Lines 2 & 3 are from 80 mg vials. Line 2 ‘Used’, line 3 ‘JW’ wastage with both lines 2 & 3 paid O.K.
3.) Lines 4 – 8 are processed fine as expected.

We have audited our own coding & cannot find any errors on point or otherwise.
Thanks so much for your attention. Best wishes!

Sincerely,
Mark Post, Admin. For Leyka M. Barbosa, MD; North Texas Joint Care, P.A.

p.s. As noted: (ICN pasted)
01/14/2020 EOMB
Our Billing NPI ***219