Latest Industry News
Knowledge is Power
Latest Industry News
Knowledge is power–Here’s what you need to know.
PROVIDERS AND SUPPPLIERS BEWARE
PROVIDERS AND SUPPPLIERS BEWARE…recent audit and program integrity activity has the potential to wreak havoc on your business. The Centers for Medicare and Medicaid Services (CMS), through their contractors, as well as through changes to their manuals, coupled with activity by the HHS Office of Inspector General (OIG) and Department of Justice (DOJ) indicates that …
CMS Updates Medicare Manual regarding Advance Beneficiary Notices
A Must-Read for Billing Departments The Centers for Medicare and Medicaid Services (CMS), on July 14, 2021, issued Transmittal 10862, Change Request 12242 (r10862CP.pdf (cms.gov)), editing, changing, and reorganizing section 50, chapter 30 of the Medical Claims Processing Manual (MCPM) (Pub. 100-04) (implemented and effective October 14, 2021) which specifically deals with the Advance Beneficiary …
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CMS Enacts New Changes to Medical Review Activities
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; …
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CMS Issues Additional Payment Edits for DMEPOS Suppliers
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 …
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CMS Pauses Elimination of the Inpatient Only List
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 …
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Provider/Supplier Medicare Appeals Process & Practice Notes
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 …
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Why Proper Documentation Matters
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 …
Medicare Administrative Contractors – Are They Treating You Fairly?
The Medicare Program Integrity Manual (MPIM)(Pub. 100-08) is a 15-chapter manual addressing all sorts of behavior by the CMS contractors charged with protecting the Medicare Trust Fund. Chapter 3, entitled “Verifying Potential Errors and Taking Corrective Actions” (MPIM Chapter 3) has set forth the following as one of its goals: The Medicare Administrative Contractors (MACs) …
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What you need to know. Auditor Update: Part 1
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 …
Auditor Update: Part II
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 …
Severe Malnutrition Added to Short-Term Acute Care PEPPER
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. …
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Auditor Update: Part III
Auditor Update: Part III Federal healthcare audits are back with a vengeance following a brief COVID-related pause. In August 2020, the Centers for Medicare & Medicaid Services (CMS) was required to resume Comprehensive Error Rate Testing (CERT) program activities that were temporarily suspended in response to the COVID-19 public health emergency (PHE). Based upon the …
One More Audit – $10,000 or More in Provider Relief Fund Payments
Earlier this week, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the distribution of approximately $9 billion in Provider Relief Fund (PRF) Phase 4 payments, from a pool of $17 billion, to health care providers who have experienced revenue losses and expenses related to the …
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OIG Work Plan and Enforcement Actions
Steven A Greenspan JD LLM There are a couple of powerful auditors looking at fraud, waste, and abuse in the healthcare arena with whom you hope to never have the pleasure of interacting. One is the Health and Human Services (HHS) Office of Inspector General (OIG). It is the largest inspector general’s office in the …
CMS Issues Additional Payment Edits for DMEPOS Suppliers
Steven A Greenspan JD LLM CMS Adds Five (5) States Requiring Licensure & Enrollment with NSC 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 …
CMS Issues Additional Payment Edits for DMEPOS Suppliers Read More »
CMS Voluntary Refunds -Concerns for Providers
William OMalley Medicare expects providers to exercise care when billing and accepting payment. Medicare also expects that providers will promptly bring incorrect payments to the Medicare Administrative Contractor’s (MAC) attention. First Coast Service Options (FCSO), on December 17, 2021, issued a notification to Medicare providers explaining that, at times, providers receive incorrect payment, such as …