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Category Archives: Billing & Reimbursement

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Nursing Home Fraud Scam Results in Conviction for “King of Nursing Homes”

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare, Practice Management

Called by some the “King of Nursing Homes” for his many low-income nursing home patients in northeast Illinois, Dr. Venkateswara Kuchipudi was recently convicted for referring patients to Sacred Heart Hospital in Chicago in exchange for kickbacks.  Kuchipudi became the fifth physician and tenth defendant to be convicted for a massive Medicare and Medicaid fraud… Continue Reading

CMS Finally Makes Reasonable Changes to 60-Day Overpayment Rule

Posted in Billing & Reimbursement, Fraud and Abuse, Health Reform, Medicare, Physician Compensation, Practice Management, Reimbursement

The Affordable Care Act (ACA) requires Medicare providers to return overpayments within 60 days of the date they are identified in order to avoid liability under the False Claims Act.  Four years ago, CMS issued a proposed rule to implement this statutory requirement that would have placed a substantial burden on providers to identify and… Continue Reading

Understanding Medicare Overpayments

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare

Under the federal Affordable Care Act, physicians and other providers have only 60 days to refund overpayments to the Medicare program before they face potential liability under the False Claims Act.  In addition, if CMS or the Medicare Area Contractor (MAC) identifies an overpayment, physicians have a limited period of time to respond or reply to the overpayment… Continue Reading

Offering Discounts (or Waivers) of Coinsurance/Copayments to Patients as an Out-of-Network Provider

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare, Practice Management, Reimbursement

Commercial payors are actively looking for ways to reduce payments to out-of-network providers.  One area of focus is discounts and waivers of patient copayments and deductibles by out-of-network providers.  In the eyes of these payors, coinsurance/copayments are essential to incentivizing patients to use in-network providers, and discounts on (or waivers of) coinsurance/copayments by out-of-network providers… Continue Reading

New Study Suggests Defensive Medicine May Be Effective in Reducing Malpractice Liability

Posted in Billing & Reimbursement, Health Reform, Malpractice Insurance, Practice Management, Reimbursement

A new study in the BMJ suggests that the more services a physician provides to his or her patients, the less likely the physician is to be sued for malpractice.  The study examined the use of resources by attending physicians in several Florida acute care hospitals during a ten-year period from 2000-2009, in relation to… Continue Reading

The Switch to ICD-10

Posted in Billing & Reimbursement, Health Reform, Medicare, Practice Management, Reimbursement

The long-anticipated implementation of ICD-10 coding finally began this past Thursday, October 1, 2015.  As of that date, government and commercial payors ceased to accept claims under the old coding system (ICD-9).  The transition has been five years in the making due to a government delay in 2012. The new system has five times the… Continue Reading

First Court Decision on the Medicare/Medicaid 60-day Overpayment Rule

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare, Practice Management, Reimbursement

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

Expanded Authority for CMS to Deny Enrollment and Revoke Medicare Billing Privileges

Posted in Articles, Billing & Reimbursement, Medicare, Practice Management, Reimbursement

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

HHS to Shift 90% of Fee-For Service Payments to Performance-Based Payments by 2018

Posted in Billing & Reimbursement, Health Reform, Medicare

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

CMS Issues FY2015 Medicare Physician Fee Schedule

Posted in Billing & Reimbursement, Medicare

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

Tips for Evaluating Provider Network Arrangements

Posted in Billing & Reimbursement, Practice Management, Reimbursement

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

What Do Your Coding Statistics Say About You?

Posted in Billing & Reimbursement, Fraud and Abuse

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

Advanced Imaging Suppliers To be Accredited by January 2012

Posted in Ancillary Services, Billing & Reimbursement, Medicare

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

Medicare Eliminates Consult Codes

Posted in Billing & Reimbursement, Medicare

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

Use the Correct Modifier When Billing for Diagnostic Tests

Posted in Billing & Reimbursement

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

Medicare Rules on Preventive Care Services

Posted in Billing & Reimbursement, Medicare

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

Changes In Medicare Enrollment Rules

Posted in Billing & Reimbursement, Medicare

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

The Office of Inspector General (OIG) Releases FY2009 Workplan

Posted in Billing & Reimbursement, Fraud and Abuse, Medicare

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