Futureproof Claims

CMS Proposes New Regulatory Language to Address Contractor Medical Review Requirements In July 2021, the Centers for Medicare and Medicaid Services (CMS) released the following proposed rule: Medicare Program: CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; …

CMS Enacts New Changes to Medical Review Activities Read More »

The Centers for Medicare and Medicaid Services (CMS) issued Transmittal 11002, Change Request (CR) 12282 (r11002otn.pdf (cms.gov), on September 13, 2021, to communicate the addition of HCPCS codes that require the use of a licensed/certified orthotist or prosthetist for furnishing custom fabricated and prefabricated (custom fitted) orthoses. These codes are in addition to those codes …

CMS Issues Additional Payment Edits for DMEPOS Suppliers Read More »

The Centers for Medicare and Medicaid Services (CMS), on November 2, 2021, issued the CY2022 Outpatient Prospective Payment System (OPPS) Final Rule (OPPS Final Rule) which, in part, paused the elimination of the Inpatient Only (IPO) list. In the CY2021 OPPS Final Rule, CMS finalized a plan to eliminate the IPO list; a list of …

CMS Pauses Elimination of the Inpatient Only List Read More »

A provider or supplier (or their representative) can utilize the Medicare Appeals Process (Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B)). However, in order for an appeal to be available, you must …

Provider/Supplier Medicare Appeals Process & Practice Notes Read More »

The Centers for Medicare and Medicaid Services (CMS) requires documentation to support coverage and payment of services provided to Medicare beneficiaries. These requirements stem directly from Title XVIII of the Social Security Act (Act), Section 1833(e): No payment shall be made to any provider of services or other person under this part unless there has …

Why Proper Documentation Matters Read More »

The number of audits is now on the upswing. The COVID pandemic caused a sharp decline in audit activity. Under the Payment Integrity Information Act of 2019 (PIIA), there is a statutory timeline required for improper payment reporting. Despite the pandemic, in August 2020, the Centers for Medicare & Medicaid Services (CMS) was required to …

What you need to know. Auditor Update: Part 1 Read More »

Shifting trends among healthcare auditors means one thing in particular for providers: they have to stay on their toes. Continued improper payment rates and high error rates serve as the basis for audit, deterrence, and prevention activity by the Centers for Medicare & Medicaid Services (CMS). Unfortunately, these medical reviews and audits can be costly …

Auditor Update: Part II Read More »

In the 34th Edition of the User’s Guide for Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER)(ST PEPPER User’s Guide), the Centers for Medicare and Medicaid Services (CMS) has included a new target area – Severe Malnutrition. Also effective with the Q3FY21 release, CMS is discontinuing the Transient Ischemic Attack target area. …

Severe Malnutrition Added to Short-Term Acute Care PEPPER Read More »