You may have heard some years ago that the Affordable Care Act established a “60-day overpayment rule” that requires a provider to report and return any overpayment from a federal health care program (such as Medicare or Medicaid) within 60 days of “the date on which the overpayment was identified” by the provider (for certain… Continue Reading
You may have heard that CMS recently expanded its authority to deny enrollment and revoke the Medicare billing privileges of providers and suppliers. The new changes could affect any physician, group practice or other Medicare provider or supplier. As the changes are wide reaching, all Medicare providers and suppliers, and anyone providing support services for… Continue Reading
Yesterday the Secretary of the Department of Health and Human Services (HHS) formally announced HHS’ intention to shift 90% of all traditional Medicare payments from fee-for-service (FFS) to quality or value-based payments by 2018. The secretary announced that HHS’ goal is to have 30% of traditional FFS payments tied to quality or value in 2016,… Continue Reading
Last week, the Centers for Medicare and Medicaid Services (CMS) issued the final Physician Fee Schedule for Fiscal Year 2015. The annual Physician Fee Schedule includes various policy and payment changes to be implemented in the coming year. This year’s Fee Schedule includes details regarding Medicare’s payment for services outside of a face-to-face visit for managing the care… Continue Reading
In response to the development of alternative payment systems, provider networks are forming at a frenetic pace. If you are like most of my physician clients, you have been or will shortly be presented with network participation agreements for review (or in many cases, signature with very little opportunity to review) and consideration. In evaluating… Continue Reading
One of the ways the Medicare program and other payer plans are recovering overpayments and identifying billing fraud is through the regular use of data mining. Simply put, by utilizing software programs that monitor and compare billing and coding data, enforcement authorities are easily able to identify problematic trends in physician billing. This is an extremely… Continue Reading
OIG has announced its priorities for 2013 and some are of special interest to physicians.
Recent press releases provide notice of activities that draw the government’s ire — and result in serious criminal consequences. Focusing on these issues is a helpful exercise for any physician trying to stay within the law.
A recent court decision concerns the method of rotating teaching physicians between multiple surgeries and billing Medicare for those services, and “whistleblower” claims when improperly done.
Physicians who reassign their right to bill the Medicare program can still be liable for false claims
My physician clients often ask me for advice on how best to negotiate with managed care payers for improved reimbursement. My advice is typically the same: if you want them to pay you more than your competitors, you have to offer them something more than your competitors do. Simply being good at what you do… Continue Reading
Under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), all Medicare suppliers of the technical component of advanced imaging services have until by January 1, 2012 to become accredited by an accreditation organization designated by the Secretary of Health and Human Services . This includes physicians, non-physician practitioners, and physician and non-physician… Continue Reading
In case you missed it, the Centers for Medicare and Medicaid Services (CMS) eliminated use of the evaluation and management Consultation Codes. Consultations are now to be billed using the standard E/M visit codes. According to CMS Transmittal 1875: "Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment.… Continue Reading
According to a recent Transmittal from the Centers for Medicare and Medicaid Services, physicians and others are using modifier -PC to designate the "professional component" of diagnostic tests. However, the -PC modifier is actually to be used to designate "Wrong Surgical or Other Invasive Procedure Performed on a Patient." Apparently many providers assume that because… Continue Reading
It is apparent that preventive care will take on greater importance in the "reformed " health care system and while Medicare historically did not cover routine or preventive screening services, the list of preventive services now covered by Medicare has grown in recent years. Physicians should familiarize themselves with the applicable coverage and billing rules so… Continue Reading
Physicians enrolling in the Medicare program should be aware that Medicare recently changed the rules applicable to when a physician’s enrollment is deemed to take effect. Specifically, the FY 2009 Medicare Physician Fee Schedule establishes that the effective date of billing for physicians and non-physician practitioners is the later of: (1) the date of filing of… Continue Reading
Does your practice bill Medicare for diagnostic tests? If so, you have until January 1, 2009 to make sure your arrangements comply with the now very complicated anti-markup rule.
The Office of Inspector General (OIG) of the Dept of Health and Human Services released its FY2009 Workplan yesterday. The Workplan outlines the initiatives and audits that the OIG expects to undertake in the coming fiscal year. Below are some of the key initiatives that the OIG expects to undertake with regard to physicians. If… Continue Reading
Under a recent decision by the U.S. Court of Appeals for the 11th Circuit, a case brought by a group of physicians against a PPO discount card company and a managed care company for appropriation of the doctors’ names and identities in connection with a plan to market and sell medical discount cards will be… Continue Reading
According to an article in the New York Times, Aetna will soon begin offering a new service to help enable patients to research their own specific medical conditions. Specifically, Aetna’s SmartSource Service will allow patients to link online research with their own medical records and claims data. While a better patient educated patient population holds… Continue Reading
A tentative settlement has been reached in a class action brought on behalf of a group of affected physicians against Blue Cross and Blue Shield plans which alleged that the plans engaged in certain misconduct that resulted in the denial or downcoding of physician claims.
The much awaited 2008 Medicare Physician Fee Schedule has finally been formally published in the Federal Register (click here to read it). The proposed Fee Schedule published in June of 2007, included a number of proposed changes to the Stark regulations as well as certain regulatory changes to the diagnostic testing rules and IDTF conditions… Continue Reading
According to a recent article in the Seattle Times, the Medicare contractor audit program which was launched in three states on a trial basis in 2005 and is expected to expand to all 50 states by 2010 could end up costing the public dearly, with potentially very little to show for the efforts. According to… Continue Reading
The New Jersey Department of Banking & Insurance has issued an order stopping Aetna’s practice of limiting non-participating physician reimbursement to 125% of Medicare. The Department has also fined Aetna almost $10,000 for violations of state insurance laws. Non-participating physicians in other states may find this development helpful in discussions with Aetna (or their insurance department, if necessary).