Medicare, Medicaid & Private Payor Updates

CBRs for Spinal Orthoses (CBR201803): What Do You Need to Know?

Medicare, Medicaid & Private Payor Updates /

(April 12, 2018): The Centers for Medicare & Medicaid Services (CMS) utilizes a variety of private contractors to process Medicare claims and conduct both administrative and program integrity audits of claims submitted by healthcare providers and suppliers.  At the present time, CMS has contracted with eGlobalTech (eGT) to analyze data and prepare “Comparative Billing Reports” […]

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ZPIC Audits / UPIC Audits: The Impact of Transmittal 768 on the Medicare Appeals Process Timeline

Medicare, Medicaid & Private Payor Updates /

(April 12, 2018): A big concern with the Medicare appeals process is the ghastly backlog at the Office of Medicare Hearings and Appeals (OMHA) for an Administrative Law Judge (ALJ) hearing coupled with the government’s authority to recoup alleged overpayments after the second level of appeal (reconsideration). There is renewed buzz regarding the backlog and

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Medicare Advantage Plans May Soon Offer Personal Care Services

Medicare, Medicaid & Private Payor Updates /

(April 10, 2018): On April 2, the Centers for Medicare and Medicaid Services (CMS) announced an expansion of the benefits that private health plans may offer Medicare beneficiaries under the Medicare Advantage (MA) program in 2019.  In its Final Call Letter for bids from plans that participate in the MA program (“MA plans”) for 2019,

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The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?

Medicare, Medicaid & Private Payor Updates /

(April 2, 2018): Our nation’s demographics are changing.  In less than 20 years, it is estimated that for the first time in country’s history, the number of individuals over the age of 65 will exceed the number of children.[1] These increases are already being seen in our rapidly expanding Medicare healthcare benefit program.  At last

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Veterans Administration and CMS Announce Partnership to Address Fraud Prevention

Medicare, Medicaid & Private Payor Updates /

(January 25, 2018): On January 23rd, the Veteran Administration (VA) and the Centers for Medicare and Medicaid Services (CMS) announced a “partnership to strengthen prevention of fraud, waste and abuse.” According to the press release, under this partnership: “VA plans to capitalize on the advancement in analytics CMS has made by concentrating on its use

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Revocation of Your Medicare Billing Privileges

Medicare, Medicaid & Private Payor Updates /

(December 14, 2017): The Centers for Medicare and Medicaid Services (CMS) has engaged various types of outside contracting entities to perform program integrity functions on behalf of the Medicare program. At the present time, Uniform Program Integrity Contractors (UPICs) and Zone Program Integrity Contractors (ZPICs) are very aggressive when it comes to referring evidence of

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UPIC / ZPIC Referrals to State Boards, Societies, Surveyors and QIOs

Medicare, Medicaid & Private Payor Updates /

(November 29, 2017): The Medicare and Medicaid programs are managed by the Centers for Medicare and Medicaid Services (CMS). CMS has engaged Unified Program Integrity Contractors (UPICs) and Zone Program Integrity Contractors (ZPICs), among others, to provide program integrity support. In the course of their duties, UPICs and ZPICs may initiate a prepayment review, postpayment

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Pain Management Prescribing Practices and Audits.

Medicare, Medicaid & Private Payor Updates /

(August 16, 2017): Earlier this summer, the U.S. Department of Justice (DOJ) executed its most extensive “health care fraud takedown” to date, initially arresting 412 licensed healthcare providers, doctors, and nurses alleged to have engaged in fraudulent conduct (additional arrests were made in the days following the takedown).  As Attorney General Jeff Sessions stated at

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Maryland Limits on Opioid Prescriptions

Medicare, Medicaid & Private Payor Updates /

(June 30, 2017): In March 2016, the Centers for Disease Control and Prevention (CDC) published “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016” [1] in an effort to address the seemingly ever-increasing deaths that have been attributed to opioid-related overdose. A number of states have passed legislation or enacted regulatory provisions

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Indiana Opioid Prescribing Guidelines–Eff. July 1, 2017.

Medicare, Medicaid & Private Payor Updates /

(June 29, 2017): Deaths resulting from a drug overdose have grown considerably in recent years. The results of a study published in “Morbidity and Mortality Weekly Report” by the Centers for Disease Control and Prevention (CDC) found that 63.1% of the overdose-related deaths in 2015 involved opioids. Notably, this was a significant increase from the

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