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Category Archives: Medicare

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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

Fix to the Medicare Physician Fee Schedule Delayed

Posted in Medicare

According to usatoday.com, The U.S. Senate will not act on legislation to fix the 21% pay cut under the Medicare Physician Fee Schedule before it goes into effect on April 1.  Although the House passed legislation earlier this week which would permanently fix the Sustainable Growth Rate formula which causes this pay cut panic every… Continue Reading

Federal Fraud and Abuse Laws Apply to Medicare Advantage Too

Posted in Fraud and Abuse, Medicare

Many physicians mistakenly believe that federal healthcare fraud and abuse statutes only apply to the Medicare fee-for-service program. However, physicians need to be aware that many federal healthcare statutes apply to any program or plan funded, in whole or in part, with federal dollars. One such example is the Medicare Advantage program. Although these plans… Continue Reading

Excluded Physician Not Precluded from Collecting Pre-Exclusion Receivables According to OIG Advisory Opinion

Posted in Fraud and Abuse, Medicare

A physician who was excluded from the Medicare program is not precluded from receiving payment for services rendered prior to the exclusion according to Advisory Opinion 15-02 published by the HHS Office of Inspector General (OIG) earlier this month.  The Advisory Opinion was requested by a physician who was excluded for 20 years from Medicare… 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

Medicare to Hold Claims for First 14 Days of 2014

Posted in Medicare

Although unlikely to have a major impact on cash flow, physicians should keep in mind that under the CY 2015 Medicare Physician Fee Schedule (MPFS) which was published in November, the Centers for Medicare and Medicaid Services (CMS) indicated that it will hold claims for 14 days in order to implement the Fee Schedule changes.  This… Continue Reading

HHS Cost Data Transparency Perhaps Not So Transparent

Posted in Health Reform, Medicare

Despite the Department of Health and Human Services’ intent to make Medicare healthcare cost data more transparent for the healthcare consumer, according to a recent report by the U.S. Government Accountability Office, current Medicare cost data, and the manner in which it is being provided, are largely ineffective in enabling consumers to make informed healthcare decisions. … Continue Reading

CMS Issues FY2015 Medicare Physician Fee Schedule

Posted in Billing & Reimbursement, Medicare, Uncategorized

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

Physicians Can Review and Correct Reported Data under the Sunshine Act

Posted in Health Reform, Medicare

Many physicians recently received a notice from the Centers for Medicare and Medicaid Services (CMS) notifying them of the opportunity to register with the CMS “Open Payments” system and review financial data reported about them by drug and device manufacturers under the federal Physician Payments Sunshine Act (“Sunshine Act”).  This had led to some confusion… Continue Reading

It’s Official (at least for now): ICD-10 Implementation Date is Now October 1, 2015

Posted in Medicare

According to a final rule published by the Centers for Medicare and Medicaid Services on August 4, 2014, providers will be required to use  the International Classification of Diseases, 10th Revision for diagnosis coding starting on October 1, 2015.  Until then providers are to continue using the 9th Revision (ICD-9). Given the winding path that ICD-10 has… Continue Reading

OIG Publishes Fraud Alert on Physician Lab Arrangements

Posted in Fraud and Abuse, Medicare

Physician ancillary service joint ventures continue to proliferate and not surprisingly, federal and state regulators are on the lookout for arrangements which may violate fraud and abuse laws .  In its recent “Special Fraud Alert: Laboratory Payments to Referring Physicians”, the Office of Inspector General (OIG) has (once again) expressed concern over financial arrangement between… Continue Reading

OIG Proposed Rule on New Civil Money Penalty Authorities

Posted in Fraud and Abuse, Medicare

The Office of Inspector General (OIG) today issued a proposed rule which would amend the federal civil monetary penalty (CMP) regulations addressing new CMP authorities created under the Affordable Care Act.  The revised regulations would allow for civil penalties, assessments, and exclusion from Medicare for and of the following: Failure to grant OIG timely access… Continue Reading

New Tool For HIPAA Security Assessment

Posted in Health Reform, Medicare, Practice Management

This past Friday, the Office of the National Coordinator for Health Information Technology, in collaboration with the HHS Office for Civil Rights and HHS Office of the General Counsel, developed a HIPAA “Security Risk Assessment Tool.”  The Security Risk Assessment Tool is a downloadable program that was developed to assist providers in performing HIPAA security… Continue Reading

CMS to Evaluate Release of Medicare Physician Payment Data on a Case-by-Case Basis

Posted in Medicare

CMS announced this week that it is modifying its longstanding policy regarding the release of Medicare physician payment data in response to Freedom of Information Act (FOIA) requests.  Since 1980, CMS’ policy has been that, for privacy reasons, it would not release Medicare payment data specific to individual physicians.  However, according to a pronouncement in the Federal… Continue Reading

Medicare Advantage Plans Terminating Physician Participation Without Explanation

Posted in Health Reform, Medicare

In recent months I have had a number of physician clients contact me to tell me that they have unexpectedly been dropped from one or more Medicare Advantage plans with which they have participated with no issue for, in some case, years.  These physicians are left somewhat bewildered because these terminations are being done without cause and without explanation.  A… Continue Reading

Physician-Hospital Integration Strategies

Posted in Health Reform, Medicare, Physician Compensation, Practice Management

As the implementation of the federal Affordable Care Act (ACA) continues in fits and starts, healthcare providers are scrambling to best position themselves to accommodate anticipated and developing payment models.  Unfortunately no one really knows what these new payment models will look like or how they will ultimately work.  It is apparent, however, that most… Continue Reading

Budget Sequester Brings Bad News for Physicians

Posted in Medicare

Unless you’ve been living under a rock for the last several weeks, you are likely well aware of the budget sequester that took effect on March 1.  The sequestration requires "across the board" cuts in federal spending.  That, in and of itself, may not be such a bad news.  However, what you may not be… Continue Reading