Tag: Medicare

Reimbursement & Regulations: E&M, Social Determinants of Health, Kickbacks

By: Andrew Minten JD
Date: December 7, 2018
Category: Custom Services
Filed under: 2019 MPFS, CMS, E/M, E&M, HHS, Inpatient Billing, Kickbacks, Medicaid, Medicare, OIG Work Plan, Reimbursement & Regulations, Social determinants of health

Return readers will be happy to hear that the CMS is delaying its changes to E&M payments. In the 2019 Medicare Physician Fee Schedule Final Rule, the CMS stated it will not be reducing E&M payments from five levels to two, but to three levels, and that it will not be doing it until 2021. […]

Reimbursement & Regulations: Sepsis, Medicare Part C, MBIs

By: Andrew Minten JD
Date: November 2, 2018
Category: Custom Services
Filed under: Anthem, CMS, DSH, HHS, MBI, Medicare, Medicare ID Cards, Medicare IDs, Medicare Part C, Reimbursement & Regulations, Sepsis, Sepsis-3, United Healthcare

Starting January 1, United Healthcare will use sepsis-3 criteria for the medical necessity of claims. Experts believe this could lead to higher denials in the near future. This change is for all of United Healthcare’s plans. Sepsis-3 defines sepsis as “life-threatening organ dysfunction caused by dysregulated host response to infection [suspected or confirmed].” Two standards […]

Reimbursement & Regulations: Price Transparency, IMRT planning, E&M

By: Andrew Minten JD
Date: September 7, 2018
Category: Custom Services
Filed under: charges, CMS, E&M, IMRT, Medicare, OIG, OIG Work Plan, Price Transparency, Radiation Therapy, Reimbursement & Regulations

The CMS has made final their rule to require all hospitals to publish a list of standard charges in a machine-readable format online at least once a year. This requirement will be in place as of January 1, 2019, so it is important to get your organization moving. The CMS created this rule in order […]

Pulse Check: Ensuring ABN Compliance

By: Andrew Minten JD
Date: August 15, 2018
Category: Custom Services
Filed under: ABN, Advance Beneficiary Notice of Noncoverage, compliance, Medicare, Patient Responsibility, price estimates, Pulse Check, Self-pay

As you well know, Advance Beneficiary Notices of Noncoverage (ABNs) are necessary whenever your organization determines that non-emergency Medicare services may not meet medical necessity. This allows the patient to determine if they want to receive the services and it alerts them to how much they may owe if the services are not found to […]

Helping Patients During the Transition to New Medicare Cards

By: Kelli Jenkins
Date: August 3, 2018
Category: Revenue Cycle
Filed under: CMS, Medicare, Medicare Beneficiary Identifier, Medicare Cards, Patient Identification

Since April 2017, CMS has been rolling out its new Medicare beneficiary cards in phases to a variety of states and territories of the U.S., and many are still awaiting their arrival. As some healthcare organizations begin to encounter patients with new cards and many more prepare to, leaders may be wondering what impact—if any—this […]

CMS’ 2019 Physician Fee Schedule Proposal: What Providers Should Know

By: Courtney Zott
Date: July 18, 2018
Category: Revenue Cycle
Filed under: CMS, Medicare, physician fee schedule

CMS proposed multiple changes last week to physician coding, documentation, and reimbursement in its proposed Physician Fee Schedule and Qualified Payment Program updates for 2019. Under the new rules, the agency would: Reimburse for certain telehealth services. Specifically, providers would receive payment for brief virtual check-ins via phone or other telecommunication device and for time […]

Reimbursement & Regulations: Stand-Alone EDs, New RAC Topics, Medicare Overpayments, and Publishing Standard Charges

By: Andrew Minten JD
Date: May 4, 2018
Category: Custom Services
Filed under: charge description master, chargemaster, CMS, duplicate claims, group 3 support surfaces, hospital costs, hospital price transparency, hospital standard costs, implantable automatic defibrillators, Medicare, Medicare overpayments, MedPAC, Off Campus ED, off-campus hospital outpatient departments, OIG, percutaneous implantation of neurostimulator electrode arrays, Price Transparency, publishing standard charges, RAC, recovery audit program, reimbursement, Reimbursement & Regulations, Stand-Alone ED

Though it is only the initial move, the Medicare Payment Advisory Commission has voted unanimously to ask federal lawmakers to reduce reimbursement for some stand-alone emergency departments (EDs) by 30%. Off-campus stand-alone EDs that operate within six miles of an on-campus hospital ED are being targeted. Roughly 66% of these facilities are owned by hospitals. […]

Pulse Check: Reduce A/R by Standardizing Follow-Up Processes

By: Andrew Minten JD
Date: April 25, 2018
Category: Custom Services
Filed under: Aetna, Billing, Blue Cross, Business Office, Cigna, Collections, Commercial Payer, follow-up, Government Payer, Medicaid, Medicare, Payers, Pulse Check

A simple way to lose out on patient service reimbursement is to send a bill to a commercial or government payer and then sit on your hands waiting for their response. Though it may seem elementary, it is important to set strategic follow-up standards for business office staff after bills have been sent out the […]

Reimbursement & Regulations: Medicare Appeal Settlements, TPE, Anthem’s ED Policy

By: Andrew Minten JD
Date: March 9, 2018
Category: Custom Services
Filed under: Anthem, Anthem Emergency Policy, Emergency Policy, Healthcare claims, Hospital Reimbursement, Medicare, Medicare Appeals, Probe and Educate, Regulations, reimbursement, Reimbursement & Regulations, Settling Appeals, Targeted Probe and Educate, TPE

Welcome back to the Reimbursement & Regulations blog series. This month I’ll be highlighting another attempt by CMS to decrease their huge amount of backlogged appeals, a new program by CMS with the goal of decreasing Medicare denials, and an update to Anthem’s emergency department reimbursement policy in certain states. As part of the CMS’s […]