"Payer: CMS|Medicare" & "Compliance" Articles


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HIPAA Penalty Changes

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On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.

Updated Stark Law and Anti-Kickback Statute Regulations Aimed at Improving Coordinated Care

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The transformation of the American healthcare system from a primarily fee-for-service system to one based on value has been one of astonishing speed and scope, touching every aspect of health care. Changes of this scale inevitably have ripple effects that impact other laws and regulations,  outdating them or highlighting inadequacies ...

Delving Into the 360 Assessment Fraud Complaint

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The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.

CMS Expands Telehealth Again

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On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.

Medicare Improper Payment Report for Chiropractic (2019)

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CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...

Medicare Improper Payment Report for Behavioral Health Services (2019)

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CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report, behavioral health services have some of the highest Part ...

Medicare Improper Payment Report (2019)

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The Medicare Improper Payment Report for 2019 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July ...

Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program

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To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.

An Infectious Disease Control Plan is Essential

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Every business encounters infections. The COVID-10 pandemic has only highlighted this fact, but considering that infectious diseases, such as the seasonal flu, are an ongoing problem, all organizations need to implement an Infectious Disease Control Plan as part of an active compliance plan because it’s required by law. Your organization must take steps to mitigate this risk to both patients and employee

Not Following the Rules Costs Chiropractor $5 Million

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Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?

New Value-Based Payment Models for Primary Care (Primary Care First and Direct Contracting)

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This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.

2021 Brings Another Risk Adjustment Calculation Change

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In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...

OIG Report Highlights Need to Understand Guidelines

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A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

Additional Telehealth Changes Announced by CMS

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On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.

SOME of Us Non-Essentials May be Able to Get Back on the Road!

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The day is coming when the freeways will have 5:00 pm stop-and-go traffic again, no doubt. However, when it comes to re-opening our world, CMS has Recommendations! Changes are finally here; we are starting to see a decline in COVID-19 cases in some states and certain locations. It may be time ...

Now That is Fraud! Genetic Testing "Public alert"

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Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

Dismal OIG Report on Telemedicine

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Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.

CMS Temporarily Suspends Contract-Level RADV Audits

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The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.

CMS Important Information on COVID-19 Released

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CMS has recently released some important information on their last MLN, the highlights are below. COVID-19: Dear Clinician Letter CMS posted a letter to clinicians that outlines a summary of actions CMS has taken to ensure clinicians have maximum flexibility to reduce unnecessary barriers to providing patient care during the unprecedented outbreak ...

CMS Announces Final 2021 HCC Risk Adjustment Changes

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On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.

2020 Medicare Part D Coverage Gap (AKA donut hole)

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Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...

Medicare Part D Coverage Gap (Donut Hole) Closes in 2020

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Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.

COVID-19: Cybercrime, Telehealth, and Coding

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Your inbox is probably like mine with all sorts of announcements about COVID-19. Here are just a few reminders of things we felt should be passed along. We have heard of several cases of cybercrime related to this outbreak. For example, there was a coronavirus map which loads malware onto your ...

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

Medicare Begins Covering Acupuncture Services

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Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.

Medicare Announces Coverage of Acupuncture Services

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On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...

Inadequate Exclusion Screenings Could Put Your Practice at Risk

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Exclusion screenings require far more than just checking a name on a federal database at the time you are hiring someone. Far too many providers don’t realize that in order to meet compliance requirements, there is MUCH more involved. There are actually over 40 exclusion screening databases/lists that need to be checked.

Denials due to MUE Usage - This May be Why!

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CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...

CMS Report on QPP Shows Increasing Involvement

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MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.


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