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
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
As of today’s date, Congress has not yet fixed or even patched the expected 21% cut to the Medicare Physician Fee Schedule. A eNews alert sent out today by the Centers for Medicare and Medicaid Services notifies physicians of the following: “The negative update of 21% under current law for the Medicare Physician Fee Schedule… Continue Reading
These days, more often than not, physicians and up on the short end of the stick when it comes to new health care legislation. However, last month a bill was introduced by Senator David Argall which, if passed, would give physicians and other healthcare providers important protection against retroactive insurance denials. Specifically, Senate Bill No.… 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
Many physicians pay very little attention to their managed care participation agreements. In fact, some simply sign these agreements without ever reading them. I think this apathy stems from the fact that managed care plans generally refuse, at least for smaller practices, to “negotiate” their fee schedules. But, even if a payor won’t negotiate fees,… Continue Reading
OIG has announced its priorities for 2013 and some are of special interest to physicians.
If you’re not sure what your managed care payers want from you, maybe you need to tell them. Many physicians are (understandably) complacent about taking an active role in defining in their payer relationships. Not surprisingly, managed care payers have had very little incentive or ability to negotiate special arrangements with a diverse and disintegrated… Continue Reading
Physician shortage may have a silver lining for physicians who choose to stay in practice: short supply means higher demand and higher demand is likely to mean increased reimbursement.
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
According to a recent study published in the September issue of Health Affairs, one of the key drivers behind the skyrocketing healthcare costs in the United States is the amount of fees payable to the physicians. According to an article published on MedPage Today, the study found that the United States spends in excess of… Continue Reading
Hospital-owned practices may take an unexpected hit in revenue under a new Medicare rule that bundles certain physician service fees into hospital payments. The so-called “payment window” rule (sometimes referred to as 3-day/1-day window rule) requires a hospital (or an entity that is wholly owned or wholly operated by the hospital) to include on the claim… Continue Reading
On November 24, 2009, the U.S. House of Representatives passed the Medicare Physician Payment Reform Act" (H.R. 3961) which would repeal the scheduled 21% fee reduction scheduled for January 2010. The legislation would also permanently replace the existing Sustainable Growth Rate (SGR) formula with a new formula that, according to the House summary: Removes items such as drugs and… Continue Reading
Despite efforts by Senator Harry Reid to pass legislation which would have effectively frozen Medicare payment rates for physicians, it looks like Congress will once again look to freeze physician payment rates with a one-year patch. According to an article published by the Wall Street Journal, Senator Reid’s proposed bill would have permanently prevented Medicare… Continue Reading
According to a recent article published on AIS Health.com, Blues plans are increasingly turning to radiology management firms to help manage costly imaging services. This is a new twist on the old "managed care" concept and, once adopted by the Blues, other major payors can be expected to follow. Physicians who provide imaging services are well advised to monitor… Continue Reading
Under what it is calling its Provencare program, Geisinger Health System is now offering patients what amounts to a ninety warranty on surgical care. Under the program – something like capitation and use of clinical protocols – insurers are charged a flat fee for which patients receive unlimited follow up care after surgery. Geisinger intends to control costs… Continue Reading
The Medicare incident-to rules permit a physician to bill for the services of auxiliary personnel as if the physician performed those services himself. You may already know that the incident-to rules require a physician to be present in the office suite and immediately available to assist while auxiliary personnel are performing incident-to services in the office. But,… Continue Reading
Both the House and the Senate have now passed the Tax Relief and Health Care Act of 2006 which, among other things, would eliminate the 5% cut in Medicare physician reimbursement that was to take effect in January 2006. The Bill is on its way to the President for signature. The text of the Bill… Continue Reading