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Hospital and Physician Usage of Devices from Physician-Owned Device Companies

October 30, 2013


In fiscal year (FY) 2012, Medicare paid hospitals a total of $3.9 billion for spinal surgeries, with the average reimbursement being $21,613 for these surgeries. A complicated spinal surgery with extensive instrumentation averages $34,676 per surgery, compared to less complicated cases at $10,289.


Medical Necessity and the Affordable Care Act

October 23, 2013


The Affordable Care Act (ACA) promises to expand care to millions of Americans, but will it happen? One factor, the medical necessity of care, will continue to serve as the key means for determining which health care services get paid or denied.


Two Similar OIG Audit Reports Result in a Lopsided Overpayment Calculation

October 16,2013


Based on information contained in the second hospital audit report, the hospital disagreed with OIG "treating them differently" and extrapolating the results, noting past hospital compliance reports only recommended hospitals repay audited claims.


CMS Moves Forward on Major Provider Revalidation Effort

October 9, 2013


Section 6401(a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011 are generally not impacted.


New CMS Rules Governing Inpatient Admissions and Documentation Requirements for Hospital Medicare Part A Payment Will Have an Impact on Admitting Physicians

October 2, 2013


The Centers for Medicare & Medicaid Services (CMS) announced this week it will delay Recovery Audit Contractor (RAC) audits of the “two-midnight” rule for 90 days. The 2014 Inpatient Prospective Payment System (IPPS) Final Rule, released in August 2013, finalized the “two-midnight” rule, under which hospital inpatient admissions that span at least two midnights presumptively qualify as appropriate under Medicare Part A, and hospital inpatient admissions that span less than two midnights (i.e., less than one Medicare utilization day) are presumptively inappropriate for payment under Part A. When auditing medical necessity, the RACs would presume that the occurrence of two-midnights after formal inpatient hospital admission indicates an appropriate in patient status for a medically necessary claim. If the occurrence of two-midnights after formal in-patient hospital admission does not occur, government recovery auditors do not apply the same presumption, and claims for such admissions receive a higher level of scrutiny.


Health Care Reform and Perhaps Your Medicare Payments May be Held Hostage by Politics

September 25, 2013


The next fiscal year begins October 1st regardless of whether it is funded or not by Congress. According to Congressional watchers, the Senate is set to hold a test vote this week on the continuing resolution legislation passed by the House to cover federal spending through December 15th and to derail funds for the Affordable Care Act (ACA).


Key Facts About the Physician Payments Sunshine Act

September 18, 2013


The collection of payment data to physicians and teaching hospitals from pharmaceutical and medical device companies, as well as reporting of certain ownership interests, under the new Physician Payments Sunshine Act (PPSA) started August 1, 2013. The law covers meals, honoraria, travel expenses, and grants from manufacturers, as well as ownership or investment interests in group purchasing organizations (GPOs), by physicians or members of their immediate family. Information will be posted on a public website that will identify physicians who have received payments or hold ownership. While data collection is underway, public reporting does not start until 2014, under the National Physician Payment Transparency Program (NPPTP) of the Centers for Medicare and Medicaid Services (CMS).


Medicare Recovery Audit Contractors Performance: Office of Inspector General Findings

September 11, 2013


Recovery Audit Contractors (RACs) are designed to protect Medicare by identifying improper payments and referring potential fraud to the Centers for Medicare & Medicaid Services (CMS). In a September 3, 2013 report, the Office of Inspector General (OIG) found that prior OIG work has identified problems with CMS's actions to address RAC referrals of potential fraud were still outstanding. Further, OIG identified vulnerabilities in CMS's oversight of its contractors.


HHS Announces First Guidance Implementing Supreme Court’s Decision on the Defense of Marriage Act (DOMA)

September 4, 2013


On August 29, the Department of Health and Human Services (HHS) issued a memo clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives. This is the first guidance issued by HHS in response to the recent Supreme Court ruling, which held Section 3 of the Defense of Marriage Act (DOMA) unconstitutional. HHS, which oversees Medicare, has decided it will adopt the “place of celebration” standard when granting Medicare benefits to same-sex couples. If the marriage took place in a state that recognizes same-sex marriage, then the couple is entitled to benefits, no matter where they live.


HIPAA –The Countdown is On to September 23

August 28, 2013


We have issued numerous alerts about compliance with the new Health Insurance Portability and Accountability Act of 1996 (HIPAA) omnibus regulations that were released on January 25 of this year (Omnibus Rule). Although much has been released about them, many are still behind in ensuring compliance with the new provisions of the rule. In a little over four weeks from now, covered entities must ensure they are complying with these new provisions or they could be leaving themselves exposed to potential liabilities of up to $1,500,000. This is a friendly reminder that there is much to do between now and September 23.


CERT A/B Contractor Task Force: Will it Streamline Coding and Billing?

August 21, 2013


United with a shared goal, all Medicare Administrative Contractors (MACs) joined forces in an August 20, 2013 national conference call to announce the formation of a new combined Part A and Part B Medicare Contractors Task Force. This Task Force will be addressing educational issues of concern leading to the Medicare improper payment errors as calculated from the Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) Program. The new initiative is independent from the CERT team and CERT Contractors’ roles, which are responsible for calculating the Medicare fee-for-service improper payment rate. During the conference call, the Part A and Part B Contractors provided an overview of the Task Force objectives and how they plan to proceed in the next few years. The Contractors’ view this new partnership as a benefit to the provider community in that this level of collaboration and consistency will help to reduce costly claim denials. The role of the A/B Task Force will be to:


Will You Be Reimbursed Fairly For Patients Enrolled In Health Insurance Exchanges?

August 14, 2013


Beginning on October 1, 2013, numerous Health Insurance Exchanges (HIE) will be open for business allowing millions of uninsured people to begin fulfilling a mandate established by the Affordable Care Act (ACA). Starting then on January 1, 2014 providers will begin to feel the impact of the ACA when these newly-enrolled subscriber's health insurance plans come into play.


Inpatient or Observation? CMS May Finally be Dealing with a Long-Standing Confusing Rule

August 7, 2013


The Centers for Medicare & Medicaid Services (CMS) and Members of Congress, have raised concerns about hospitals’ use of observation stays and short inpatient stays. Over the years there has been confusion as to when a patient should be classified as an inpatient as opposed to an outpatient or in observation status. CMS proposed a hospital inpatient prospective payment system (IPPS) rule for FY 2014, published in the May 10, 2013 Federal Register, updating the current observation rule. The proposal would streamline the rule in that admissions spanning at least two midnights will presumptively qualify as inpatient admissions for payment (under Medicare Part A); when an admission spans less than two midnights it will be considered an outpatient visit (paid under Medicare Part B). CMS does allow the documentation in the medical record to overcome these presumptions. For example, a patient who is only in the hospital for one midnight census can be considered an inpatient if he or she left earlier than expected by the physician and the documentation in the medical record supports the physician's expectation that the patient would be in the hospital longer. The proposed rule can be found on the Government Printing Office website.


Bridging the Healthcare Gap? Nurses and Physician Assistants Taking over Physicians’ Duties.

July 31, 2013


Recently, nurses and physician assistants have seen an expansion in their scope of practice, allowing them to perform tasks that have traditionally been reserved for licensed physicians. The reason for this trend is twofold. First, it is widely agreed that our country is currently experiencing a physician shortage, especially in the primary care arena. Secondly, with the enactment of the Patient Protection and Affordable Care Act (“PPACA”) in 2010, millions of Americans will soon gain health insurance coverage, and the current healthcare system does not have enough physicians to administer their care. The reasons supporting and opposing expanding nurses and physician assistants’ scope of practice are many. It is with this landscape and the consistently diminishing reimbursement to healthcare providers, generally, that the industry is presented with the challenge of providing more patients with quality care more efficiently.


Achieving Gold, Silver, or Bronze Hospital Ratings: What The Rating Systems Means And Why Should Hospitals Be Concerned?

July 24, 2013


Hospital Compare was introduced in April 2005 as part of the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative. The Hospital Quality Initiative uses a variety of tools to help stimulate and support improvements in the quality of care delivered by hospitals. The intent is to help improve hospitals’ quality of care by distributing objective, easy to understand data on hospital performance, and quality information from consumer perspectives.


CMS 2014 Outpatient Prospective Payment System (OPPS) Proposed Rule Could Significantly Impact Hospital Evaluation and Management (E/M) Coding and Reimbursement

July 17, 2013


The Centers for Medicare and Medicaid Services (CMS) is proposing to collapse the current five levels of outpatient visit codes with a single Healthcare Common Procedure Coding System (HCPCS) code for each unique type of outpatient hospital visit; one for clinic and one for each type of emergency department visit (24 hour and non-24 hour). CMS believes that collapsing the current five levels of codes to one level will: 1) remove incentives hospitals may have to provide medically unnecessary services or expend additional, unnecessary resources to achieve a higher level of visit payment under the hospital Outpatient Prospective Payment System (OPPS); 2) reduce administrative burden and be easily adopted by hospitals; and 3) allow a large universe of claims to be utilized for rate setting.


What Does a One Year Delay Mean for Healthcare Providers?

July 10, 2013


Last week, the Obama Administration announced in a Treasury Department blog post, that the White House said it would delay until 2015 the Affordable Care Act’s (ACA) requirement that businesses with more than 50 employees offer insurance. Those businesses were to face a $2,000 per worker penalty (minus the first 30 workers) for not doing so starting next year. According to the Administration this is designed to meet two goals. First, it will allow the Administration time to consider ways to simplify the new reporting requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees. "We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively," Mark Mazur, PhD, assistant secretary for tax policy at the Treasure Department, noted in his blog post announcing the move. "We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so.”


Patient Financial Interactions and Satisfaction

July 2, 2013


The key to improving all aspects of performance (clinical, financial and operational) is to really listen to what your patients are saying and act on those insights. With the movement to Hospital Value-Based Purchasing (VBP) and the integration of the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey into a portion of the Inpatient Prospective Payment System (IPPS) hospitals are targeting how they may better communicate with their patients to improve their satisfaction with their total care experience.


Addressing Medicare Payment Differences Across Sites of Care

June 26, 2013


The Medicare Payment Advisory Commission (MedPAC) has been addressing Medicare payment differences across ambulatory settings. Currently, Medicare’s payment rates often vary for the same ambulatory services provided to similar patients in different settings, such as physicians’ offices, hospital outpatient departments (OPDs), and ambulatory surgical centers (ASCs). Services that are covered under the fee schedule for physicians and other health professionals, also known as the physician fee schedule (PFS), have two payment rates: one for when the physician provides the service in his or her office (the non-facility rate) and another for when the physician provides the service in a facility such as a hospital outpatient department (OPD), other provider-based entity, or ambulatory surgical center (the facility rate). When a service is provided in a physician’s office, there is a single payment for the service. However, when a service is provided in a facility, Medicare makes a payment to the facility in addition to the payment to the physician. As more physicians shift from free-standing practices to hospital-based outpatient clinics, MedPAC is concerned Medicare spending will increase, as payment rates for hospital outpatient departments are higher than for physicians' offices.


Medicare Urges Seniors to Join the Fight Against Fraud

June 19, 2013


The Centers for Medicare and Medicaid Services (CMS) is ramping up their efforts to involve Medicare senior citizens in the government’s ongoing battle to fight health care fraud and abuse. Several new initiatives were recently announced by CMS:


CMS Compliance Countdown Calendars

June 12, 2013


Today’s discussion is about several fast-approaching deadlines.  These include: CMS e-prescribing penalty, Physician Quality Reporting System (PQRS), Electronic Health Records (EHR), Meaningful Use (MU), Health Insurance Portability Accountability Act (HIPAA), and the conversion from version 9 to 10 of the International Classification of Diseases codes (ICD-10).  Let’s review each of these programs and what their looming compliance or effective dates mean to health care providers’ future revenue.


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