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
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
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 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
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