Medicare, Medicaid & Private Payor Updates

Wake Up Sleep Labs! OIG is Concered About Questionable Billing Practices

Medicare, Medicaid & Private Payor Updates /

(October 24, 2013): Over the next year, sleep lab / sleep medicine practices and clinics should expect to receive increased scrutiny from both the Department of Health and Human Services, Office of Inspector General (OIG) and from program integrity contractors working for the Centers for Medicare and Medicaid Services (CMS). These contractors may include Zone […]

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Should You be Concerned About a Consultant Qui Tam?

Medicare, Medicaid & Private Payor Updates /

(October 16, 2013): Healthcare providers should be on guard – a new type of whistleblower may be an individual you would least expect. Recently, the Department of Justice (DOJ) entered into a multi-million dollar settlement agreement with a Florida-based healthcare provider based on claims that the provider submitted false claims to various Federal and State

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Complying with an Individual’s Request to Restrict the Submission of PHI to Insurance

Medicare, Medicaid & Private Payor Updates /

(October 3, 2013): The HIPAA Omnibus Rule (Omnibus Rule) is well over 100 pages long. When considered in the context of existing HIPAA and HITECH, health care providers are often it difficult to apply the provisions of the Omnibus Rule to privacy situations that are commonly arising in a physician’s practice. One such situation is

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Texas Medical Board Complaints are Serious Business!

Medicare, Medicaid & Private Payor Updates /

(September 20, 2013): Like other physicians around the country, Texas physicians are currently facing increasing pressures to ensure that their medical necessity determinations, coverage assessments, documentation, coding and billing activities meet both Medicare’s requirements and those of private payors. While their duties and responsibilities have continued to increase, reimbursement rates have steadily fallen. Notably, Texas

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Are Your Outpatient Therapy Claims Ready For Manual Medical Review by a Medicare RAC?

Medicare, Medicaid & Private Payor Updates /

(September 5, 2013): Since April 1, 2013, Medicare’s Recovery Audit Contractors (RACs) have been conducting manual medical reviews for all Medicare Part B therapy services that exceed a $3,700 threshold. There has been some early confusion on behalf of outpatient therapy providers, and the Centers for Medicare and Medicaid (CMS) have been bombarded with questions

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Prepayment Reviews and Postpayment Audits are Increasing in Frequency — New Guidance has Been Issued to ZPICs

Medicare, Medicaid & Private Payor Updates /

(September 3, 2013): On August 21, 2013, the Centers for Medicare & Medicaid Services (CMS) released “Transmittal 485/Change Request 8079”. This transmittal imposes an obligation on Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) to notify a health care provider prior to placing them on the provider on prepayment or postpayment review. There

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Strategic Health Solutions has Initiated an E/M Claims Audit of 99214 and 99215

Medicare, Medicaid & Private Payor Updates /

(August 15, 2013): Over the last few months, Strategic Health Solutions, LLC, a Supplemental Medical Review Contractor, appears to have significantly stepped up its post-payment audits of physicians and non-physician practitioners billing high level Evaluation and Management (E/M) codes. Strategic Health Solutions’ current audit push appears to be focused on E/M services provided to established

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When Did You Last Review Your Private Payor Contracts? You Need to Analyze Before You Sign!

Medicare, Medicaid & Private Payor Updates /

(August 14, 2013): In today’s reimbursement environment, solo physicians and physician practice groups are witnessing a steady decline in reimbursement rates. Unfortunately, their overhead costs and obligations due to the imposition of Electronic Medical Records, HIPAA Privacy, OSHA and a litany of other regulatory requirements are making more and more difficult to remain profitable each

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Strategic Health Solutions is Merely the Latest CMS Contractor to Flex its Audit Muscles

Medicare, Medicaid & Private Payor Updates /

(May 9, 2013): Strategic Health Solutions is an Omaha, Nebraska-based company that provides professional health care education and audit services for both federal and state government agencies. In recent months, a wide range of physicians (working in specialty areas ranging from endocrinology to pain management) have received audit letters asking for supporting documentation associated with

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Recovery Audit Contractor Changes will be Major in 2014

Medicare, Medicaid & Private Payor Updates /

(May 7, 2013): The Recovery Audit Contractor (RAC) program is slated to undergo significant changes in 2014. As discussed below, non-hospital health care providers and suppliers are likely to find the Medicare appeals process more complex than ever as RACs enter into the process in an effort to defend their denial decisions. I. Background of

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