Tag: Reimbursement & Regulations

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: Emergency Plan, H&P, & Transplant Centers

By: Andrew Minten JD
Date: October 12, 2018
Category: Custom Services
Filed under: CMS, Emergency Plans, Emergency Preparedness, Medical History and Physical Examination, Reimbursement & Regulations, Transplant Centers

Since the OIG only has two new Work Plan focuses this month, and because neither deal with hospital reimbursement on a broad level, this month I will only focus on a new Rule proposed by the CMS. On September 20, 2018 the CMS released a new proposed rule with the purpose of reducing more of […]

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 […]

Reimbursement And Regulations: E/M Codes, Anthem ED, Medicare Compliance

By: Andrew Minten JD
Date: August 3, 2018
Category: Custom Services
Filed under: Anthem, Anthem Emergency Policy, Cataract Removal, CPT codes, E/M Codes, E/M Payments, Evaluation and Management, Medical Students, Medicare Compliance, Medicare Compliance Newsletter, Reimbursement & Regulations

In keeping with its crusade to decrease the amount of paperwork physicians are saddled with, the CMS is proposing a sweeping change to how medical evaluation and management (E/M) codes will be reimbursed. This is potentially very large news, depending on what services are provided at your organization. The current structure for E/M codes have […]

Reimbursement & Regulations: ADR Guidelines, Stark Law and OIG Updates

By: Andrew Minten JD
Date: July 6, 2018
Category: Custom Services
Filed under: Additional Documentation Requests, ADR, CERT, Comprehensive Error Rate Testing, documentation request, Error Code 99, ESRD Medicare Part B, MAC, Medicare Administrative Contractor, Medicare Dialysis, Medicare Part B Dialysis, OIG Work Plan, Reimbursement & Regulations, Stark Law, value-based care

The CMS is requesting more information! This time, it is looking to reduce “undue regulatory impact and burden” created by the Stark Law. The Stark Law was created to reduce physician self-referrals and other financial conflicts of interest, but organizations have been arguing for years that the Stark Law has made it difficult to comply […]

Reimbursement and Regulations: Value-Based Reimbursement, Price Transparency, and OIG Updates

By: Andrew Minten JD
Date: June 1, 2018
Category: Custom Services
Filed under: 2019 IPPS, chargemaster, CMS, Humana, IPPS, noninvasive home ventilators, OIG, OIG Work Plan, outpatient cardiac and pulmonary rehabilitation services, Price Transparency, reimbursement, Reimbursement & Regulations, respiratory assist devices, value-based care, value-based reimbursement

Though the transition from fee-for-service to value-based care is dreadfully slow (which makes sense with how many factors there are to juggle), commercial payers have been stepping up to the plate. Aetna and United Healthcare have stated that more than 45% of their total annual medical spend is in value-based contracts. As a recent highlight, […]

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. […]

Reimbursement & Regulations: CDM Updates, Cardiac Device Credits, and Revenue Code 456

By: Andrew Minten JD
Date: April 6, 2018
Category: Custom Services
Filed under: Cardiac Device Credit, Cardiac Devices, CDM, CDM Maintenance, Coding, OIG, OIG Audit, Reimbursement & Regulations, Rev Code 456, Revenue Code 456, Revenue Codes

Though you are hopefully already aware, on April 1, 2018, Medicare updated the Hospital Outpatient Prospective Payment System (OPPS). It is now paying for nonpass-through drugs, biologicals, and therapeutic radiopharmaceuticals that are not acquired through the 340B Program at the average sales price plus 6%. It is important to update your charge description master to […]