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The 340B drug discount program continues to be in a state of flux The American Hospital Association (AHA) recently filed suit to stop reductions to the 340B drug program. On Dec. 29, 2017, the lawsuit was dismissed by the judge, who ruled: “In conclusion, plaintiffs’ failure to present any concrete…
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Five major areas will challenge IRF providers in 2018, including the troublesome “presumptive compliance.” Let’s face it: there are a multitude of areas that Inpatient Rehabilitation Facility (IRF) leadership must focus on every day to be successful. As we begin a new year of compliance with a plethora of regulations,…
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Two new programs have significant potential in collectively effectuating a meaningful reduction in the appeals backlog. In casting a larger net, the Office of Medicare Hearings and Appeals (OMHA) hopes to engage more providers and suppliers in settlement agreements as it seeks to improve the Medicare claims appeals process by…
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CMS requires that all total knee replacements performed on fee-for-service Medicare beneficiaries are performed in a hospital.  AUTHOR’S NOTE: Since the release of the 2018 Outpatient Prospective Payment System (OPPS) Final Rule, there have been many varying opinions on how to determine the proper status for patients undergoing total knee…
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Without congressional action, new therapy caps became effective Jan. 1, 2018. Going into 2018, Medicare beneficiaries will have therapy benefits capped at $2,010 for physical therapy (PT) and speech-language pathology (SLP) combined, and the same limit for occupational therapy. Congress recessed for the holiday break without addressing the expiration of…
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The CMS announcement will be discussed in a conference call on Jan. 9, 2018. Healthcare providers and suppliers with fewer than 500 appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council could be eligible to participate in a new low-volume appeals (LVA) settlement…
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Confusion persists as providers anxiously await facility-specific guidelines from CMS. Did UHC provide to facilities an ED criterion to use when assigning facility ED evaluation and management (E&M) codes to their patients?  Probably not.  Based on this, most facilities have used the Centers for Medicare & Medicaid Services (CMS) instructions…
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Two key areas the federal review contractors will be targeting next. An MLN Matters article published on Dec. 11 reported on a recent advisement from the Centers for Medicare & Medicaid Services (CMS) to its medical review contractors related to therapy services in Inpatient Rehabilitation Facilities (IRFs). Consistent with what…
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New RAC issues proposed for auditing appear to baffle the author As promised, the Centers for Medicare & Medicaid Services (CMS) has posted its December 2017 list of issues that are being considered for Recovery Audit Contractor (RAC) auditing. And as expected, a few of the proposed issues appear a…
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The OIG has added specialty drug coverage and reimbursement by Medicaid to its Work Plan.  In October, the OIG added specialty drug coverage and reimbursement by Medicaid to the list of active Work Plan items. This was in addition to the continuing Medicaid-related prescription drug reviews for the 2017 fiscal…