Tagged with Medicare Billing
On February 20, CMS issued a proposed rule which recommends a three-year extension and changes to the episode definition and pricing in the Comprehensive Care for Joint Replacement (CJR) Model.
CMS Administrator, Seema Verma, on February 11, announced the agency’s intent to reform prior authorization regulations later this year. According to Verma, the changes “will reduce administrative waste, increase patient safety and free physicians to spend time caring for their patients.”
On February 13, CMS introduced a new code that enables labs conducting Coronavirus tests to bill for the specific test instead of using an unspecified code.
UnitedHealthcare has announced plans to implement certain changes to enhance the Procedure to Modifier Policy for Medicare Advantage plans to include modifiers CT, FX and FY.
On February 5, CMS released Part II of the Calendar Year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. In the CY 2021 Advance Notice, the agency is proposing updates and changes to the methodologies used to pay MA plans, Programs of All-Inclusive Care for the Elderly (PACE) organizations, and Part D sponsors.
As a guide for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries, CMS has released an update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. The agency hopes the update will promote national correct coding methodologies and to control improper coding that can lead to inappropriate payment in Part B claims.
On January 17, CMS issued a memorandum providing additional guidance clarifying Medicare-Medicaid integration requirements for Dual Eligible Special Needs Plans (D-SNPs). The memorandum is intended to clarify distinctions between fully integrated D-SNPs (FIDE SNPs) and highly integrated (HIDE SNPs); permissibility of carve-outs of behavioral health services and long term services and supports (LTSS) for FIDE SNPs and HIDE SNPs; alignment of D-SNP and companion Medicaid plan service areas; and compliance with integration requirements for DSNPs that only enroll partial-benefit dually eligible individuals.
CMS has released a payment advisory alerting certain clinicians who are Qualifying APM participants (QPs) and eligible to receive an Advanced Alternative Payment Model (APM) Incentive Payment for 2019, that the agency does not have the current banking information needed to disburse the payment and provides information on how to update banking information to receive this payment.
RTI International and U.S. Department of Health and Human Services, Answering the Medical Expenditure Panel Survey
By Jeanne A. Gilreath, OHCC, CHBME, Senior Vice President & Chief Compliance Officer Question: What is my obligation to provide information to RTI, who calls our office stating that (s)he is “calling on behalf of the U.S. Department of Health and Human Services (HHS) for Medical Expenditure Panel Survey (MEPS)?” It seems that the representatives…
On October 9, the Department of Health and Human Services (HHS) announced proposed changes that seek to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the Stark Law) and the Federal Anti-Kickback Statute. The proposed rule has been designed to provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposed changes are intended to ease the compliance burden for healthcare providers across the industry while maintaining strong safeguards to protect patients and programs from fraud and abuse.
The American College of Radiology (ACR) is seeking help in its efforts to urge Congress to stop CMS from implementing proposed changes to the Evaluation and Management (E/M) Codes that could result in severe cuts to radiology.
Humana has published its latest medical claims payment policy updates, including its reimbursement policy for ambulance transportation, requirements for billing and documentation of observation services, as well as a new policy for obstetric billing, including antepartum, delivery and postpartum care.
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In a letter to the House Ways and Means Committee, Chairman Richard Neal has proposed that the Departments of Health and Human Services (HHS), the U.S. Labor and Treasury Department, along with other interested parties, consolidate their efforts to develop standards for rates for surprise bills.
The president, on October 3, signed an executive order directing the Department of Health and Human Services to increase efforts to provide more insurance plan options under Medicare Advantage and to remove regulations that are considered burdensome to health care providers. The order is intended to protect traditional Medicare and private Medicare Advantage while ramping up alternative payment models, time spent with patients, access to innovative technology and reducing the regulatory burdens on providers.
A U.S. District Judge has overturned a CMS rule that had reduced Medicare reimbursement rates for off-campus hospital clinic visits.
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.
By Jeanne A. Gilreath, CHBME, Senior Vice President and Chief Compliance Officer One of the many programs CMS has implemented to help providers identify billing issues is the Targeted Probe and Educate (TPE) audit program. It is designed to identify providers with high denial rates or unusual billing practices according to CMS. If a provider is…
Effective July 1, Aetna will require prior authorization for certain procedures under its Enhanced Clinical Review Program with eviCore healthcare.
Effective September 1, UnitedHealthcare (UHC) will add a new policy for molecular pathology and will make changes to its procedure to modifier policy.