The Centers for Medicare & Medicaid Services (CMS) has issued proposed regulations and a new form to address the requirements of the NOTICE (Notice of Observation Treatment and Implication for Care Eligibility) Act. This change to the SSA (Social Security Act) was enacted on Aug. 6, 2015 and is scheduled to go into effect on or about Aug. 6, 2016. CMS has included the proposed CFR (code of federal regulation) changes …Read more
The Centers for Medicare & Medicaid Services (CMS) has unveiled and launched a major expansion of its Comprehensive Primary Care (CPC) Plus model initiative for primary care physicians. It is the agency's largest-ever plan to transform and improve how primary care is delivered and reimbursed, with Medicare working with commercial payors and state Medicaid programs. The expansion of the CPC model, as released on April 11, would pay a monthly fee to …Read more
According to Chapter 8, Section 126.96.36.199 of the Medicare Program Integrity Manual, “sampling units are the elements that are selected according to the design of the survey and the chosen method of statistical sampling. They may be an individual line(s) within claims, individual claims, or clusters of claims (e.g., a beneficiary). For example, possible sampling units may include specific beneficiaries seen by a physician during the time period under review; …Read more
We are continuing our reporting on New Mexico's mental health situation. In June 2013, 15 providers responsible for 87 percent of the behavioral health services delivered in New Mexico were stripped of their contracts. The ostensible reason was the presence of “credible allegations of fraud.” Two years later, New Mexico's Attorney General found that there never were any credible allegations...Read more
Value-based purchasing, bundled payments, Medicare Advantage, required quality reporting, and many Centers for Disease Control and Prevention (CDC) requirements all have one thing in common: they require reporting along an axis not defined by the Centers for Medicare & Medicaid Services (CMS) in its five criteria for a reportable secondary diagnosis. As a reminder, those five criteria are the following: 1) Evaluation...Read more
The time has come for me to get a little philosophical. During the April 4 edition of Monitor Mondays, we learned that the Recovery Auditors (RAs) are going to increase the number of their skilled nursing home (SNF) billing audits because previous audits demonstrated an increasing number of patients with ultra-high therapy resource utilization groups (RUGs) who just happened to...Read more
Those who appreciate a good horror story will enjoy this article, which illustrates how very minor mistakes can spiral into abject disaster. A physician group that provides various prosthetics to patients recently had a durable medical equipment (DME) validation survey. When the surveyor sent an email with many typos, the physician group doubted the authenticity of the surveyor’s assertion that he...Read more
Predatory contractor auditors use dirty tricks to extrapolate huge sums of money that they contend must be paid back. Now you'll learn how to see behind their devious methods and protect your facility's revenue and reputation through this important and accessible webcast — a must attend for anyone in your facility dealing with claim denials.
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