Medicare, Medicaid & Private Payor Updates

CMS Expands ALJ Appeal Claim Settlement Process to Include Part A Providers

Medicare, Medicaid & Private Payor Updates /

(April 4, 2016) In an effort to reduce the enormous backlog of pending Administrative Law Judge (ALJ) appeals, the Centers for Medicare and Medicaid Services (CMS) recently announced that it has expanded the pilot Settlement Conference Facilitation (SCF) process to include Part A claims. This process, which was previously only available to providers with pending […]

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Texas SNFs — Medicare Audits of Ultra High Therapy Claims are Here!

Medicare, Medicaid & Private Payor Updates /

(March 16, 2016): Last week, the Centers for Medicare & Medicaid Services (CMS) released a new dataset which provides detailed information on services provided by skilled nursing facilities (SNFs) to Medicare beneficiaries. This data set is known as the “Skilled Nursing Facility Utilization and Payment Public Use File” (SNF PUF), as is part of CMS’s

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Coverage and Payment of New Products – CPT / HCPCS Code Issues

Medicare, Medicaid & Private Payor Updates /

(January 12, 2016): With the advent of the Affordable Care Act and the changes in the payment incentives that are being developed by payors, including the Medicare and Medicaid programs, many emerging companies are developing new products and devices for the market. While companies will take these products through the regulatory process of obtaining FDA

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Providers, Hospitals, and the CJR Program – What You Need To Know!

Medicare, Medicaid & Private Payor Updates /

(January 12, 2016): In our previous article on this subject, we discussed the new Comprehensive Joint Replacement program (CJR program) that CMS has initiated. Under that program, Medicare will pay approximately 800 hospitals in 67 MSAs a bundled payment to cover the costs of virtually all the care that is related to the treatment of

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DME Audits are Back! Are Your Claims Compliant?

Medicare, Medicaid & Private Payor Updates /

(December 22, 2015): The number of durable medical equipment (DME) audits conducted by Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) have surged in recent years. Medicare contractors have gradually increased their scrutiny of DME suppliers’ claims. This has resulted in increased postpayment audits of DME suppliers’ claims and associated overpayment demands made

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Exclusion Screening Enforcement Actions by OIG are Increasing.

Medicare, Medicaid & Private Payor Updates /

(December 8, 2015): Since the passage of the Patient Protection and Affordable Care Act of March 2010[1] (ACA) and progeny such as the HITECH Act [2], enforcement efforts have been better funded and consequently, better staffed. The enactment of HIPAA in 1996 [3] and the Balanced Budget Act (BBA) of 1997 [4], further expanded the

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Does Your Practice Have a Compliance Officer or Compliance Committee?

Medicare, Medicaid & Private Payor Updates /

(October 29, 2015): Last month we discussed why having a functioning, effective compliance program is important. If done correctly, a compliance program that is functional, effective, and well-documented is as important as your medical malpractice liability insurance. Indeed, the Affordable Care Act now requires compliance programs and many private payers now explicitly require compliance programs

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Medicare Fraud Enforcement Efforts Are Rising in Texas

Medicare, Medicaid & Private Payor Updates /

(October 27, 2015): Over the past year, Medicare fraud enforcement efforts throughout Texas have resulted in multiple convictions.  These increased enforcement efforts should serve as a reminder to all Texas health care providers and suppliers that full compliance with applicable statutory and regulatory requirements is not an option — it is a necessity. I. Medicare

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Medicare Ophthalmology Audits: Is Your Practice Ready?

Medicare, Medicaid & Private Payor Updates /

(October 26, 2015): Last month, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) released a study entitled “Questionable Billing for Medicare Ophthalmology Services.” As the study findings reflect, the OIG concluded that for the year 2012, approximately $171 million of the Medicare payments made that year for ophthalmology services were

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