Providers should keep in mind that such policies aren’t binding – but can offer valuable direction. Imagine your Medicare Administrative Contractor (MAC) had a policy detailing their coverage of records documented by a scribe.  Say that policy had been revoked. You have located a policy by another MAC, CGS. Would it be…
Noridian uses scenarios for the parenteral administration of iron in non-dialysis patients. The Noridian iron infusion Local Coverage Determination (LCD) is important for just about everyone since Noridian is the Supplemental Medical Review Contractor (SMRC). Noridian could end up reviewing and denying your claims even if you’re not in Noridian’s…
Author finds fault with WPS policy. You might think that you could rely on the accuracy of a Medicare Administrative Contractor (MAC) policy, but apparently, you can’t.  First, I’d like to extend thanks to my colleague Sharon for sending me WPS’s deeply flawed split/shared evaluation and management (E&M) policy. If…
OMHA’s new eligibility requirements are intended to benefit more providers. The Office of Medicare Hearings and Appeals (OMHA) has expanded its Settlement Conference Facilitation (SCF) program, and it is now open to the appellant community. By way of background, Settlement Conference Facilitation (SCF) is an alternative dispute resolution process designed…
The MAC is proposing an LCD for vertebral augmentation procedures. The controversy over the vertebral augmentation procedures kyphoplasty and vertebroplasty continues with a just-released proposed Local Coverage Determination (LCD) from Noridian, a Medicare Administrative Contractor (MAC). In this LCD, for which comments are now being accepted, Noridian is proposing to…
Could recoupments be unconstitutional? Case law is changing in favor of healthcare providers who accept Medicare and/or Medicaid. Without question, accepting Medicare and/or Medicaid payments creates a legal risk of regulatory audits. Because the reimbursements constitute tax dollars, the federal and state governments (sometimes via a contracted entity) have the…
Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC). Extrapolation is a veritable tsunami in…
Although the details of federally ordered auditing of providers have changed over the years, one thing remains the same. We have lived for years under the Sword of Damocles – the continuing waves of healthcare audits by federal contractors. The names of the Medicare Recovery Audit Contractors (RACs) have changed…
“Urgent” memo marks obvious disagreement among contractors. In what can only be described as highly unusual, a Medicare Administrative Contractor (MAC) has advised home health providers who have had claims audited and denied by the Comprehensive Error Rate Testing (CERT) contractor to appeal those denials. The announcement was made today…
Latest move by CMS raises more questions. CGS, a Medicare Administrative Contractor (MAC), on Thursday released an email notice indicating that the Centers for Medicare & Medicaid Services (CMS) has instructed it to stop seeking recoupment or issuing demand letters for Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) Hospital…
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