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Category Archives: Medicare

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What is the Medicare Quality Payment Program and How May It Affect My Practice?

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

There are big changes coming to the Medicare incentive programs as we know them.  Beginning on January 1, 2017, the new Quality Payment Program (the “Program”) will replace all existing Medicare incentive programs with a comprehensive incentive model.  The Program will involve a modified set of EHR Meaningful Use requirements, new quality of care metrics,… Continue Reading

Upcoming Deadline to Apply for ‘Hardship Exception’ to 2015 Meaningful Use Requirements — July 1, 2016

Posted in Articles, Medicare, Physician Compensation, Practice Management

The deadline for providers to file a hardship exception application to the electronic health record (EHR) meaningful use requirements for the 2015 reporting period is July 1, 2016. If you have any concern that your practice or certain eligible professionals in your practice may have been unable to meet the meaningful use requirements for the 2015 reporting… Continue Reading

OIG Issues Advisory Opinion on Transportation Aid and Lodging Benefits

Posted in Fraud and Abuse, Medicare, Practice Management

In a recent Advisory Opinion (No. 16-02), the OIG concluded that it would not seek sanctions against a state-run hospital (the “Hospital”) under the federal anti-kickback statute or the civil monetary penalty law for two arrangements under which the Hospital provides transportation aid and short-term lodging to pregnant women covered by federal health care programs.… Continue Reading

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

OIG Issues Favorable Advisory Opinion on Patient Assistance Charitable Foundation

Posted in Fraud and Abuse, Medicare

This week the Office of Inspector General (OIG) published Advisory Opinion 15-16 addressing a 501(c)(3) charitable foundation (the “Requestor”) that would seek donations from third parties (including drug manufacturers) and provide financial assistance with out-of-pocket patient expenses for outpatient prescription drugs. Under the proposed arrangement, the Requestor would maintain two disease funds, one of which would provide… Continue Reading

OIG Issues Advisory Opinion Regarding Radiology Transcription Feeds

Posted in Fraud and Abuse, Medicare

This week, the Office of Inspector General (OIG) issued OIG Advisory Opinion No. 15-15 regarding a proposed arrangement in which a hospital would bill a radiology group for transcription of the radiology group’s reports for patients who are not hospital patients, but rather patients of a third-party clinic that provides radiology studies and refers to… Continue Reading

CMS Publishes Draft Plan for Quality Measurement in Support of Payment Reform

Posted in Health Reform, Medicare

The Centers for Medicare & Medicaid Services (CMS) has stated its intention to move at least 50% of Medicare payments from fee for service to alternative payment systems based on quality and/or value by 2018.  In furtherance of this goal, the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) passed… 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

Centers for Medicare and Medicaid Services Published New FAQs on EHR Incentive Programs and Final Rule on Stage 3 Participation

Posted in Health Reform, Medicare

This past month, CMS published several new Frequently Asked Questions  (FAQs) on its website addressing questions about the EHR incentive programs, and in particular how to attest to certain measures for health information exchange, patient electronic access, and other objectives that require patient action.  Those FAQs can be found here on the CMS website. CMS… 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

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