Medicare Advantage plans have reacted to industry criticism of their limited coverage expansion of SdoH. I expected a buzz over our recent Monitor Mondays report and RACmonitor article about the limited coverage expansion of the social determinants of health (SDoH) by Medicare Advantage (MA) plans. Actually, there have been a…
Providers are encouraged to file protective appeals. “In section XI of the preamble of the proposed rule, we discussed the growing number of Provider Reimbursement Review Board (PRRB) appeals made by providers and the action initiatives that are being implemented with the goal to decrease the number of appeals submitted;…
Coding Guidelines and Conventions trump Coding Clinic. Hats off to coders.  This group of medical information professionals is required to master one of the most convoluted and confusing set of rules known to civilized man in order to categorize hospital services and submit their findings to insurance companies for billing.…
HHS ordered back to the drawing board – and told to work quickly. A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal…
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…
Keeping patients in LTACHs longer than necessary can increase reimbursement. Two years ago, on Monitor Mondays and in the RACmonitor eNews, Ronald Hirsch, MD told the story of one of his patients, Carl, whose stay at a skilled nursing facility (SNF) seemed to be stretched to 20 days to maximize…
A proposed 50 percent reduction in claims submitted with modifier 25 is on the table. The Centers for Medicare & Medicaid Services (CMS) is proposing a 50 percent reduction in reimbursement for claims submitted using modifier 25, according to Shannon DeConda, an evaluation and management (E&M) coding expert. DeConda reported…
Significant – and wildly varying – changes to reimbursement loom ahead. You don’t have to be a coder to realize what the financial impact of proposed changes from the Centers for Medicare & Medicaid Services (CMS) will be, or to see that there will be winners and losers. Using 2016…
There are now 200,000 new targets for CMS and private payers. Since the first of this year, I have engaged in several audits for which the target is not the physician, but rather a physician’s assistant (PA) or a nurse practitioner (NP). While there have always been audit issues regarding…
Relationships with drug and device companies come with risk. Fortunately, the risk is manageable by using common sense to structure payments. Imagine you’re in a clinic or hospital and a medical device company representative approaches you and says, “we think you’re doing wonderful work. We’d love to use you to showcase…
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