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I have written four previous articles on Philip Esformes, who was sentenced to 20 years in federal prison for a truly infamous scheme to defraud Medicare out of millions of dollars. He bribed doctors and other providers of care to send patients to his skilled nursing homes.At his sentencing, Judge…
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Credible allegations of fraud is a low standard to meet. If you are accused of Medicare fraud, your Medicare reimbursements will be immediately cut off without any due process or ability to defend yourself against the allegations. If you accept Medicare and Medicaid, then you are held to strict regulations,…
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Moderna’s vaccine is expected to be shipped to providers nationwide, on the heels of Pfizer’s. A reeling nation couldn’t have asked for a better Christmas present. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine for individuals 16 and older last week…
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Vote on the continuing resolution (CR) helps providers with Advanced Payments. The U.S. Senate passed a continuing resolution (CR) this evening, which will keep the federal government open through the middle of December. As the government’s fiscal year ends today (Wednesday) at midnight, the CR was passed just in time.…
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Providers forced to camouflage in mediocrity.  EDITOR’S NOTE: This the first in a series of articles that explores the use of algorithms in the auditing of medical claims. The Centers for Medicare & Medicaid Services (CMS) has pioneered the use of computer algorithms for detection of fraud. These efforts leverage technologies…
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Telehealth and immunizations are two of numerous services targeted for revision. Federal officials are seeking public comments from providers on an expansive set of sweeping revisions to policies governing Medicare payments. The Centers for Medicare & Medicaid Services (CMS) announced the recommended revisions via a proposed rule issued late last…
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Minorities have been found to be disproportionately affected by adverse outcomes. Federal officials say their first monthly statistical update illustrating the impact of the COVID-19 virus on the Medicare population leaves no doubt: minorities are being disproportionately affected by the continuing pandemic.   The Centers for Medicare & Medicaid Services…
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Today is the first day that prior authorization is required for Medicare beneficiaries to undergo specific surgeries. Here are the 10 things you need to know about the program. Five types of surgery – blepharoplasty, botulinum toxin injections to the face, panniculectomy, rhinoplasty, and vein ablation – performed on traditional…
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It is the hospital’s responsibility to obtain the prior authorization.  We are two weeks away from the start of the Medicare prior authorization program, and as of June 17, the Medicare Administrative Contractors (MACs) were required to start accepting requests. As a reminder, five procedure classes will need prior authorization:…
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There is continued confusion over the use of patient homes as off-campus, provider-based clinics for Medicare billing purposes. This is the provision in the Centers for Medicare & Medicaid Services’ (CMS’s) second recent Interim Final Rule (IFR) that allows hospitals to bill for services provided by employed hospital staff, such…