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"Quality Payment Program" & "Compliance" Articles
Click on the title to see the article summary and a link to the full article.
January 11th, 2021
HIPAA Penalty Changes
By Wyn Staheli, Director of Research | Published January 11th, 2021
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.
December 7th, 2020
Updated Stark Law and Anti-Kickback Statute Regulations Aimed at Improving Coordinated Care
By Jared Staheli | Published December 7th, 2020
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 ...
October 12th, 2020
Medicare Improper Payment Report for Chiropractic (2019)
By Jared Staheli | Published October 12th, 2020
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 ...
October 12th, 2020
Medicare Improper Payment Report for Behavioral Health Services (2019)
By Jared Staheli | Published October 12th, 2020
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 ...
October 12th, 2020
Medicare Improper Payment Report (2019)
By Jared Staheli | Published October 12th, 2020
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 ...
October 7th, 2020
Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program
By Wyn Staheli, Director of Research | Published October 7th, 2020
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.
October 6th, 2020
An Infectious Disease Control Plan is Essential
By Wyn Staheli, Director of Research | Published October 6th, 2020
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
September 1st, 2020
Not Following the Rules Costs Chiropractor $5 Million
By Wyn Staheli, Director of Research | Published September 1st, 2020
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?
August 7th, 2020
Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices
By Wyn Staheli, Director of Research | Published August 7th, 2020
On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.
July 28th, 2020
OIG Report Highlights Need to Understand Guidelines
By Wyn Staheli, Director of Research | Published July 28th, 2020
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.
April 22nd, 2020
COVID-19 Clinical Trial Participation Helps Providers Earn MIPS Credit
By Wyn Staheli, Director of Research | Published April 22nd, 2020
All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.
April 20th, 2020
Dismal OIG Report on Telemedicine
By Wyn Staheli, Director of Research | Published April 20th, 2020
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.
April 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
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.
March 25th, 2020
COVID-19: Cybercrime, Telehealth, and Coding
By Wyn Staheli, Director of Research | Published March 25th, 2020
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 ...
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020
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: ...
January 21st, 2020
Inadequate Exclusion Screenings Could Put Your Practice at Risk
By Wyn Staheli, Director of Research | Published January 21st, 2020
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.
January 6th, 2020
CMS Report on QPP Shows Increasing Involvement
By Wyn Staheli, Director of Research | Published January 6th, 2020
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
October 1st, 2019
2020 Official ICD-10-CM Coding Guideline Changes Are Here!
By Wyn Staheli, Director of Research | Published October 1st, 2019
It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...
August 20th, 2019
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
August 13th, 2019
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
By Wyn Staheli, Director of Research | Published August 13th, 2019
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.
August 9th, 2019
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
July 22nd, 2019
Are These Problems Hurting Your Practice?
By Wyn Staheli, Director of Research | Published July 22nd, 2019
There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.
July 15th, 2019
Denial Management is Key to Profitability
July 8th, 2019
Q/A: Can I Put the DC’s NPI in Item Number 24J for Massage Services?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Question:
Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services?
Answer:
While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
July 1st, 2019
Rules for Rendering Unproven, Investigational or Experimental Procedures
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published July 1st, 2019
If you haven’t reviewed your state guidelines or taken a recent look at third-party payer policies on unproven, investigational or experimental procedures, now is the perfect time to make sure you’re up to speed with this important information. Most providers are surprised to see commonly used devices or techniques listed ...
July 1st, 2019
Q/A: Do I Really Need to Have an Interpreter?
By Wyn Staheli, Director of Research | Published July 1st, 2019
Question:
I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true?
Answer:
Yes! There are both state and federal laws that need to be considered. The applicable federal laws are:
Title VI of the Civil Rights Act of 1964,
Americans with Disabilities ...
June 27th, 2019
2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done
By Wyn Staheli, Director of Research | Published June 27th, 2019 - Last Review/Update July 8th, 2019
The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...
June 25th, 2019
Q/A: Can I Refuse to File a Patient's Medical Insurance for an Auto Accident?
By Wyn Staheli, Director of Research | Published June 25th, 2019
Question:
Can a Chiropractor refuse to file a patients Medical Insurance for an Auto Accident?
Answer:
There isn't a simple answer to this question. It depends on who is responsible and state laws. Who is responsible (the auto insurance or the medical insurance) can depend on state requirements as well as who is ...
June 21st, 2019
Small Breaches Can Be Subject to Large Penalties
By Namas | Published June 21st, 2019 - Last Review/Update June 27th, 2019
Small Breaches Can Be Subject to Large Penalties
We may have heard about the large fines issued by the Office for Civil Rights (OCR) against big organizations like Anthem or the University of Texas MD Anderson Cancer Center. These organizations have been in the news due to privacy breaches that constituted violations ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
May 13th, 2019
Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?
By Wyn Staheli, Director of Research | Published May 13th, 2019
Question
We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate ...
April 29th, 2019
Q/A: I’m Being Audited? Is There a Documentation Template I can use?
By Wyn Staheli, Director of Research | Published April 29th, 2019
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...
April 23rd, 2019
OIG Announces New Review For Medicare Part B Payments for Podiatry and Ancillary Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 23rd, 2019
Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020. The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.
Part of the ...
April 23rd, 2019
Let's Talk High Risk E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
April 15th, 2019
Watch out for People-Related ‘Gotchas’
By Wyn Staheli, Director of Research | Published April 15th, 2019
In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...
April 8th, 2019
Prepayment Review Battle Plan
By Wyn Staheli, Director of Research | Published April 8th, 2019
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
March 25th, 2019
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
March 22nd, 2019
Q/A: How do we Know Which Codes a Payer Will Allow?
By Wyn Staheli, Director of Research | Published March 22nd, 2019
How do we know which codes a payer will allow?
The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...
March 7th, 2019
Date of Service Reporting for Radiology Services
By Wyn Staheli, Director of Research | Published March 7th, 2019
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
March 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
February 14th, 2019
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
By Aimee Wilcox | Published February 14th, 2019
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
February 7th, 2019
Charging Missed Appointment Fees for Medicare Patients
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
January 14th, 2019
Q/A: Is G8730 Still Required? Are G Codes Required at all?
By Wyn Staheli, Director of Research | Published January 14th, 2019 - Last Review/Update January 21st, 2019
G8730, when is it required. Many G codes are still active and are required for non-quality reporting.
December 18th, 2018
Quality Measures Finalized for 2019
By Wyn Staheli, Director of Research | Published December 18th, 2018
CMS recently announced that the quality measures for 2019 have been finalized. There are new eligible clinicians so be aware of how that may affect your organization. New ECs are:
Physical therapists
Occupational therapists
Qualified speech-language pathologists
Qualified audiologists
Clinical psychologists
Registered dietitian or nutrition professionals
The following are changes to Electronic Clinical Quality Measures (eCQMs) available ...
December 18th, 2018
Medicare Advantage Providers are not Required to be Enrolled in Medicare
By Wyn Staheli, Director of Research | Published December 18th, 2018
There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to ...
December 18th, 2018
Are HIPAA Changes Coming?
By Wyn Staheli, Director of Research | Published December 18th, 2018
On December 14, 2018, the Office for Civil Rights (OCR) issued a Request for Information (RFI). They are considering making changes to some of the HIPAA regulations. Earlier this year at the HIMSS (Healthcare Information and Management Systems Society) meeting, Roger Severino, the head of the Office for Civil Rights ...
December 7th, 2018
Keeping Up to Date
By NAMAS | Published December 7th, 2018 - Last Review/Update December 20th, 2018
Keeping up to date on coding and documentation changes, is critical for medical coders, billers, auditors, and compliance personnel. Every year American Medical Association (AMA) creates, revises, and deletes CPT codes on January 1st. Same thing occurs with the ICD-10 codes in October. For CPT codes, the intention of the...
November 29th, 2018
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
November 28th, 2018
No Good Deed Goes Unpunished
By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA | Published November 28th, 2018 - Last Review/Update January 21st, 2019
You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.
November 9th, 2018
Billing 99211 Its not a freebie
By | Published November 9th, 2018 - Last Review/Update November 29th, 2018
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
November 7th, 2018
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
October 22nd, 2018
Q/A: Does My LMT need an NPI? How do I Bill Her Services?
By Wyn Staheli, Director of Research | Published October 22nd, 2018 - Last Review/Update December 19th, 2018
Question:
I am setting up an LMT to work as employee under Dr. Clifton, DC. i need to know several things - hoping they are related and can be grouped into this one question.... does she need her own NPI? where does that NPI # go? what box #? if not, ...
September 28th, 2018
Chiropractic OIG Audit Recommendations - Lessons Learned
By Wyn Staheli, Director of Research | Published September 28th, 2018
The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following:
Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year ...
September 26th, 2018
HIPAA Handling Patient Requests for Medical Record Restriction
By | Published September 26th, 2018 - Last Review/Update October 17th, 2018
Healthcare compliance professionals frequently face confusing situations about sharing of protected health information (PHI). The Health Insurance Portability and Accountability Act (HIPAA) supports the protection of privacy of medical records. However, even when a patient does not authorize sharing of his record, there are permitted uses and disclosures, such as...
September 24th, 2018
Q/A: Do I Have to Accept Any New Patient?
By Wyn Staheli, Director of Research | Published September 24th, 2018 - Last Review/Update January 28th, 2019
Question: Is it legal for us to not allow a patient to be seen in our office if their parents have bad debt with us?
August 31st, 2018
Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations
By Wyn Staheli, Director of Research | Published August 31st, 2018
In January, the U.S. Department of Health and Human Services (HHS) issued updates to the privacy regulations regarding the confidentiality of patient information of substance use disorder patients (42 CFR Part 2). This notice included references to better alignment with HIPAA regulations, but did state that Part 2 is more protective ...
August 20th, 2018
PSAVE Pilot Program - What Does it Mean to You?
By Wyn Staheli, Director of Research | Published August 20th, 2018
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
August 13th, 2018
Are incident to services worth the risk
By | Published August 13th, 2018 - Last Review/Update September 24th, 2018
Incident-to services allow non-physician practitioners (NPPs) such as nurse practitioners and physician assistants to bill under a supervising physician if they perform services that are incidental to a physician-created plan of care. Incident-to billing offers two key benefits: First, the physician is reimbursed at 100% of the contracted rate with...
August 3rd, 2018
Q/A: Is it Legal to Shred Archived Patient Records After a Certain Amount of Time?
By Wyn Staheli, Director of Research | Published August 3rd, 2018 - Last Review/Update January 28th, 2019
Shredding patient records. When is it appropriate? Read more to find out.
July 17th, 2018
Attention Providers - Please Make Time to Read this Letter
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 17th, 2018
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
July 12th, 2018
Dual Medicare-Medicaid Billing Problems
By Wyn Staheli, Director of Research | Published July 12th, 2018
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...
June 26th, 2018
WHO Said ICD-11 is Coming Soon
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 26th, 2018
Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...
June 25th, 2018
Small Practices are Affected by MIPS Increased Thresholds
By Wyn Staheli, Director of Research | Published June 25th, 2018
We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part ...
June 25th, 2018
How Does the Physician Compare Website Affect You?
By Wyn Staheli, Director of Research | Published June 25th, 2018
The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...
June 18th, 2018
Medicare Claim Submission Exceptions
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 28th, 2019
There are several exceptions to the Medicare "Mandatory Claim Submission Rule." What are they?
June 18th, 2018
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 30th, 2019
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
June 15th, 2018
The Money in MIPS
By Diana Strubler | Published June 15th, 2018 - Last Review/Update July 3rd, 2018
Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), recently announced that 91% participated in the first year of the Quality Payment Program (QPP), barely squeaking by their goal of 90%....
June 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
By Raquel Shumway | Published June 14th, 2018
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
June 11th, 2018
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
June 7th, 2018
The Range of Motion Conundrum
By Gregg Friedman, DC, CCSP | Published June 7th, 2018 - Last Review/Update January 30th, 2019
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
May 30th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
May 30th, 2018
Routine Waiver of Patient Out of Pocket Expenses
By Linda Walker | Published May 30th, 2018 - Last Review/Update June 4th, 2018
Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient's co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations....
May 30th, 2018
What is a Legal Hold and e Discovery Anyway
By Rachel V. Rose, JD, MBA | Published May 30th, 2018 - Last Review/Update June 4th, 2018
Whether I am assisting clients or presenting, I am often asked about legal holds and e-discovery. The transition from paper to electronic records, which include emails, computer faxes, protected health information ("PHI"), personally identifiable information ("PII") and documents that are created, received, maintained or transmitted in an electronic format created...
May 22nd, 2018
Q/A: Am I Supposed to List the Frequency and Duration on the ABN?
By Wyn Staheli, Director of Research | Published May 22nd, 2018 - Last Review/Update January 28th, 2019
How to fill out Box D (Services) on the ABN form. What information is required?
May 7th, 2018
Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?
By Wyn Staheli, Director of Research | Published May 7th, 2018 - Last Review/Update January 30th, 2019
A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?
May 4th, 2018
The Devil is in the Data Details
By J. Paul Spencer, CPC, COC | Published May 4th, 2018 - Last Review/Update May 24th, 2018
As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.
April 30th, 2018
Q/A: Should I be Using Modifier 96 on PT Claims?
By Wyn Staheli, Director of Research | Published April 30th, 2018 - Last Review/Update January 30th, 2019
As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?
April 23rd, 2018
Q/A: Someone Broke into My Office. What do I do Now?
By Wyn Staheli, Director of Research | Published April 23rd, 2018 - Last Review/Update January 24th, 2019
My office was broken into last night. I use electronic health records, but we do store some protected health information for my patients in paper files. These files are not secured, so the burglars did have access to them. It did not appear that the files were touched as the burglars were looking for cash. What responsibilities to I have to my patients in a situation like this? Do I need to contact them and advise them that their PHI could have been compromised?
April 20th, 2018
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
April 9th, 2018
CMS Compliance Guidelines Focused Trainings
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 9th, 2018
Since the publication of the Compliance Program Guidelines in 2012, the Medicare Part C & D Oversight and Enforcement Group, Division of Compliance Enforcement, has presented a series of focused trainings for the industry on the application of the seven elements of an effective compliance program. These trainings are designed ...
March 8th, 2018
Documentation for Home Health Services (Part A non DRG)
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medical Learning Network provides coverage guidance, which should be documented, for home health services.
March 8th, 2018
Documentation for Skilled Nursing Facilities
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).
February 23rd, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published February 23rd, 2018 - Last Review/Update February 26th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
February 2nd, 2018
Scoring & Reporting Your Audit Findings
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published February 2nd, 2018 - Last Review/Update February 7th, 2018
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
February 1st, 2018
Using a 2015 Certified EHR in MIPS Year 2
By Diana Strubler | Published February 1st, 2018
The following information is from BC Advantage. As of Dec 31, 2017, Acumen EHR v8.0 achieved Office of the National Coordinator for Health Information Technology (ONC-Health IT) 2015 edition certification! What's a 2015 CEHRT?A CEHRT (Certified EHR Technology) is defined by CMS specifically for their incentive payment programs such as...
February 1st, 2018
OIG Reviews Medicare Advantage Claims
By Wyn Staheli, Director of Research | Published February 1st, 2018
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that:
"Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
January 31st, 2018
Mobile Health: Growing Engagement and New Responsibilities
By Dugan Maddux, MD, FACP | Published January 31st, 2018 - Last Review/Update March 29th, 2018
This week I'm blogging about an M-word. Not MACRA or MIPS, but Mobile Health or mHealth....
January 31st, 2018
Developing Coding Policies for Compliance
By Marge McQuade, CMSCS, CHCI, CPOM | Published January 31st, 2018
Every physician practice depends upon correct coding and billing for their financial success. Coding drives reimbursement. All of the resources available for coding information and guidance are meaningless without the practice manager translating it into provider-specific coding policies and compliance plan. As a practice manager, you need to develop a ...
January 29th, 2018
Dental and Medical- Controlled Substance Awareness
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2018
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
January 26th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC | Published January 26th, 2018 - Last Review/Update February 7th, 2018
This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....
January 24th, 2018
HIPAA and the Opioid Crisis
By Wyn Staheli, Director of Research | Published January 24th, 2018
HIPAA and the Opioid Crisis guidance released by HHS.
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 22nd, 2018
Compliance: What is it and Why is it Important
By Joan S. Hartman, RHIT | Published January 22nd, 2018 - Last Review/Update January 25th, 2018
Compliance. It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important?
January 16th, 2018
Patient Relationship Codes
By Wyn Staheli, Director of Research | Published January 16th, 2018
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
January 10th, 2018
New MIPS Reporting Option for 2017 Data
By Wyn Staheli, Director of Research | Published January 10th, 2018
On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated:
Data can be submitted and updated any time from January 2, 2018 to March ...
January 4th, 2018
CMS Launches Data Submission System for Clinicians in the Quality Payment Program
By Find-A-Code | Published January 4th, 2018
Today, the Centers for Medicare & Medicaid Services (CMS) announced that doctors and other eligible clinicians participating in the Quality Payment Program can begin submitting their 2017 performance data using a new system on the Quality Payment Program website (qpp.cms.gov). The data submission system is an improvement from the former...
January 2nd, 2018
Quality Payment Program in 2018
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
December 21st, 2017
OIG Advisory Opinion Recinded - Lessons Learned
By Wyn Staheli, Director of Research | Published December 21st, 2017
In the compliance world, it is important to know when the OIG makes an advisory opinion on a subject. For example, the advisory on Time of Service or Prompt Pay Discounts helps to ensure that providers are creating policies and procedures which will meet the standards of the OIG in the case ...
December 15th, 2017
Is Your Practice in Need of a Wellness Visit?
By Valora Gurganious, MBA, CHBC | Published December 15th, 2017 - Last Review/Update January 31st, 2018
Is your practice busier than ever, but net practice income continues to drop?
December 13th, 2017
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
By Jared Staheli | Published December 13th, 2017
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
December 12th, 2017
Developing Billing & Coding Policies
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
The financial health of every medical practice rests upon correctly coded claims. This is true from not only a financial standpoint since coding drives reimbursement, but from a compliance perspective as well. All of the resources available for coding information and guidance are meaningless without the practice manager sifting through...
December 11th, 2017
Quality Payment Program Resources
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
December 1st, 2017
Auditing the Use of a Scribe
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published December 1st, 2017 - Last Review/Update January 31st, 2018
A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......
November 30th, 2017
Why You Should Stop Using ROM as an Outcome Measure
By Dr. Ron Feise, Practice Consultant and Coach with RJF Consulting - www.chiroevidence.com | Published November 30th, 2017 - Last Review/Update January 30th, 2019
We received this email from a chiropractic colleague: “I recently attended a
continuing education seminar accredited by a chiropractic college. The presenter
was talking about outcome measures and highly recommended cervical and
lumbar range of motion (ROM) as a good outcome measure for patients with
spinal conditions. But I am hesitant to use ROM, because it seems to be
inconsistent with a patient’s status.”
What does the current research demonstrate?
November 16th, 2017
Can an Unlicensed Person Perform Physical Therapy Services Such as 97110?
By Wyn Staheli, Director of Research | Published November 16th, 2017 - Last Review/Update January 30th, 2019
Can an unlicensed person perform code a 97110 service as long as they're under doctor supervision? I use only PT, ATC, or DC's to perform these codes and I've been told that I don't need such highly qualified therapists to perform therapy.
November 7th, 2017
Four Final Rules Affecting CMS Payments for 2018
By Wyn Staheli, Director of Research | Published November 7th, 2017
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ...
November 6th, 2017
New Payment Rulings Could Affect You
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
November 6th, 2017
Payment Rulings and Small Provider Practices
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
November 3rd, 2017
Importance of Outcomes Measurements
By Wyn Staheli, Director of Research | Published November 3rd, 2017
One important component of health care reporting is the utilization of quality measures which are typically classified into one of three broad categories: structure, process, or outcome.
Structural measures define the healthcare provider’s capacity, systems, and processes (e.g., EHR use, ratio of providers to patients)
Process measures indicate what providers do to ...
October 23rd, 2017
Summary of OIG Reports for Chiropractic
By | Published October 23rd, 2017
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
October 13th, 2017
Can Chiropractors Opt-out of Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
October 6th, 2017
Your NAMAS Weekly Auditing & Compliance Tip for October 6, 2017
By NAMAS | Published October 6th, 2017 - Last Review/Update October 16th, 2017
October 6, 2017
Acronyms and Abbreviations: When You Fall Into The Grey Area
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before.
The language is unclear, the acronym(s) could mean so many different things, and it's hard to get ...
September 29th, 2017
Stark Law for Healthcare Providers
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published September 29th, 2017
Be aware of physician self-referral laws and how they affect your practice.
September 29th, 2017
Does Every Visit Need to Document Quality and Quantity of Pain & Update the Treatment Plan?
By ChiroCode | Published September 29th, 2017 - Last Review/Update February 5th, 2019
Does every single visit need to document quality and quantity of pain and an update to the treatment plan?
September 29th, 2017
Don't do the MIPS Minimum
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published September 29th, 2017 - Last Review/Update March 4th, 2019
Doing the MIPS Minimum - Penny Wise but Pound Foolish?
Are you planning to “do the MIPS minimum” - the “Test” reporting option - in 2017 and submit the minimum amount of data possible to avoid the penalty? Perhaps every silver lining does not have a cloud, but “Pick Your Pace” sure does. Just as we cheered when the SGR was buried, only to see MIPS emerge from the grave, perhaps the “Pick Your Pace” regulations should undergo more scrutiny before we throw our hats into the air at this regulatory “reprieve.”
September 25th, 2017
Last Chance to Start Reporting MIPS
By ChiroCode | Published September 25th, 2017 - Last Review/Update February 5th, 2019
MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best.
September 14th, 2017
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
September 1st, 2017
Medicare Improper Payment Report for Chiropractic (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 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 ...
September 1st, 2017
Medicare Improper Payment Report for Behavioral Health Services (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 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 ...
September 1st, 2017
Medicare Improper Payment Report (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 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 ...
September 1st, 2017
2017 Physical Therapy Evaluation & Management Codes
By Kathy Price, RHIT, CPC, CCS-P, CPMA | Published September 1st, 2017 - Last Review/Update January 31st, 2018
As you know, 2017 brought us new evaluation and management codes for physical and occupational therapy....
September 1st, 2017
Quick Tip from ChiroCode -- Documentation
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 31st, 2019
Documentation Solutions, a quick tip video by Dr Gwilliam.
August 29th, 2017
Quality Measures for Chiropractic - 2017
By Wyn Staheli, Director of Research | Published August 29th, 2017
Performance Measurement Codes for Chiropractic:
Although there are hundreds of Performance Measurement (PM) services and events, only two may be reported for chiropractors for the 2017 reporting year.
Pain Assessment and Follow-Up
131
ENCOUNTER: 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, ...
August 24th, 2017
Q/A: MIPS and G Codes
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 24th, 2017 - Last Review/Update February 5th, 2019
We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good?
August 17th, 2017
Q/A: What are the Rules for a Fill-in (locum tenens) Doctor?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 17th, 2017 - Last Review/Update February 5th, 2019
A locum tenens provider is one that works in the place of the regular physician for a short duration of time. Guideline typically allows this time period to be a 60 day maximum, when a substitute doctor would be brought in to your office to cover your original doctor's actual schedule during the time he/she is absent.
Read further for more information
August 4th, 2017
Cybersecurity - Are you sure you are secure?
By Wyn Staheli, Director of Research | Published August 4th, 2017
An article by Medical Economics highlights the June report of the Health Care Industry Cybersecurity Task Force. Their report confirmed once again that healthcare providers are not adequately addressing cybersecurity as part of the compliance programs. The threat of hackers is very real and providers need to ensure that they have taken ...
June 30th, 2017
Getting Serious About Your Practice’s Compliance
By Jesse Overbay, JD | Published June 30th, 2017
By now, hopefully most (if not all) practices know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan for most of this decade. In its own words, the OIG believes "that a healthcare provider can use internal controls to ...
June 28th, 2017
Medicare Announces New Cards to Be Issued
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
May 5th, 2017
Your MIPS Resources
By Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP | Published May 5th, 2017 - Last Review/Update March 5th, 2019
What is MIPS and what now?
April 14th, 2017
Compliance Rules
By ChiroCode | Published April 14th, 2017 - Last Review/Update February 8th, 2019
Can we send a survey to our patients and still be compliant? Are there rules that regulate this?
April 14th, 2017
Office of Inspector General (OIG) - Compliance Program Guidance
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 14th, 2017
The compliance program guidance documents are listed below.
09-30-2008Supplemental Compliance Program Guidance for Nursing Facilities (73 Fed.Reg. 56832; September 30, 2008)
Compliance Program Guidance for Nursing Facilities (65 Fed. Reg. 14289; March 16, 2000)
11-28-2005Draft Compliance Program Guidance for Recipients of PHS Research Awards (70 Fed.Reg. 71312; November 28, 2005)
NSTC Launches Government-Wide Initiative ...
April 10th, 2017
False Claim Penalties Increase Again
By Wyn Staheli, Director of Research | Published April 10th, 2017
On February 3, 2017, the Department of Justice (DOJ) issued a Final Rule to increase the civil monetary penalties assessed under the False Claims Act (FCA), due to inflation for the year 2017, to an all-time high of $10,957 (minimum) to $21,916 (maximum). Thirty years ago, in 1986, Congress amended the False ...
February 27th, 2017
Opting Out of MIPS & MACRA
By ChiroCode | Published February 27th, 2017 - Last Review/Update February 8th, 2019
Question: Is it true that I can opt out of MIPS & MACRA if my part B charges are less than or equal to $30,000? If so, are the charges based on covered Medicare charges (98940, 98941, 98942) or all charges sent to Medicare? Some patients want non-covered charges sent to Medicare too.
February 27th, 2017
How to Properly Dispose Protected Health Information (PHI)
By InstaCode Institute | Published February 27th, 2017
HIPAA requires covered entities to properly dispose of Protected Health Information (PHI) in the following manner:
Paper, film, or other hard copy media has been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed.
Electronic media has been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media ...
February 23rd, 2017
Physician Compensation Fraud Alert
By Wyn Staheli, Director of Research | Published February 23rd, 2017
In June 2015, the Office of Inspector General (OIG) issued a Fraud Alert focused on physicians and compensation arrangements. Providers need to ensure that these arrangements do not violate the Anti-Kickback Statute. Healthcare providers found to have committed fraud are subject to possible criminal, civil and administrative sanctions.
In this alert ...
February 23rd, 2017
Medicaid Reviews
By Wyn Staheli, Director of Research | Published February 23rd, 2017
All federal healthcare programs are required to implement programs to prevent and reduce provider fraud, waste, and abuse and this includes the Medicaid program. Two groups work in conjunction with the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG):
the Medicaid Integrity Program (MIP) works at ...
February 23rd, 2017
Emergency Preparedness Final Rule
By Wyn Staheli, Director of Research | Published February 23rd, 2017
Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs).
There are specific standards for each of the named types of providers ...
February 6th, 2017
Quality Reporting is not Just for CMS
By Wyn Staheli, Director of Research | Published February 6th, 2017
If you thought that quality reporting is just for CMS, you are wrong. Other payers recognize the need to establish quality metrics.
January 23rd, 2017
Virtual Groups and MIPS
By Wyn Staheli, Director of Research | Published January 23rd, 2017
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
January 23rd, 2017
Why Should I Document a Differential Diagnosis?
By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP | Published January 23rd, 2017 - Last Review/Update February 8th, 2019
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.
January 23rd, 2017
Q/A: Where Can I Find More Information on HIPAA Penalties?
By ChiroCode | Published January 23rd, 2017 - Last Review/Update March 5th, 2019
Neglecting or overlooking a sound HIPAA Compliance policy can be crippling to a practice.
Where can I find more information on HIPAA penalties?
January 16th, 2017
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
January 13th, 2017
Q/A: Is my Software Vendor a Business Associate to my Practice?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published January 13th, 2017 - Last Review/Update February 8th, 2019
Q: Is my software vendor a business associate to my practice?
December 28th, 2016
Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume
By ChiroCode | Published December 28th, 2016 - Last Review/Update February 8th, 2019
The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.
December 19th, 2016
Benchmarks
By Wyn Staheli, Director of Research | Published December 19th, 2016
Benchmarking is simply a standard or point of reference against which things may be compared or assessed. For all businesses, it is a way of comparing your business processes to another business in the same industry to determine where shortfalls exist or improvements can be made to maintain profitability.
December 15th, 2016
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
By Brittney Murdock, QCC, CMCS, CPC | Published December 15th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
December 15th, 2016
How do I Determine who is a Business Associate to Our Practice?
By ChiroCode | Published December 15th, 2016 - Last Review/Update March 5th, 2019
How do I determine who is a Business Associate?
December 12th, 2016
60 Day Final Rule
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
October 17th, 2016
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
October 14th, 2016
Q/A: Are You Liable When a Business Associate Has a Data Breach?
By ChiroCode | Published October 14th, 2016 - Last Review/Update March 5th, 2019
We have a Business Associate who has recently had a data breach, are we liable?
September 24th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2015)
By Wyn Staheli, Director of Research | Published September 24th, 2016
Medicare claims review sheds light on problem areas for behavioral health providers.
September 9th, 2016
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
July 29th, 2016
Cloned E/M notes
By | Published July 29th, 2016
Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note? Well, Medicare contractors have noticed the same thing, and the Office of Inspector General has included this on their 2011 Work Plan. Medicare contractors have noted an...
July 29th, 2016
What's My Benefit For Implementing Compliance Solutions
By ChiroCode | Published July 29th, 2016 - Last Review/Update March 4th, 2019
Lots of Chiropractic practices want to know why compliance is necessary and how implementing compliance can help the practice.
July 28th, 2016
Pre-op visits: True or False?
By | Published July 28th, 2016
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the...
July 28th, 2016
OIG adds to increased scrutiny of how patients pay for rising share of drug costs
By | Published July 28th, 2016
Charity programs that help patients pay for the rising cost-sharing obligations of needed drugs may run afoul of anti-kickback rules when the charity’s scope is so narrow that it guides the patient toward specific drugs for treatment or providers, the HHS Office of Inspector General said last week.The OIG’s Supplemental...
July 28th, 2016
OIG Work Plan to look at excessive patient billing, place of service errors
By | Published July 28th, 2016
The 2014 OIG Work Plan has finally been released and, while it doesn’t have a lot of new issues for physician practices, there are definitely some areas worth your attention to avoid future compliance hassles. If you’ve been wondering where it’s been, the OIG decided to change the timing of...
July 28th, 2016
OIG Work Plan 2012-Do your own review of these areas
By | Published July 28th, 2016
The Office of Inspector General released its Work Plan for 2012. As in past years, the Work Plan describes the areas of interest that the OIG will investigate in the coming year. There are sections for hospitals, nursing homes, and of course, physicians. There is a pdf file attached to...
July 5th, 2016
Q&A: We just learned that for Meaningful Use attestation, we have to complete a Security Risk Assessment. What is that and how do we do it?
By ChiroCode | Published July 5th, 2016 - Last Review/Update March 4th, 2019
Q&A:
We just learned that for Meaningful Use attestation, we have to complete a Security Risk Assessment. What is that and how do we do it?
June 21st, 2016
Voluntary Overpayments
By Wyn Staheli, Director of Research | Published June 21st, 2016
When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.
June 16th, 2016
Q&A: Will Using Lower Level Codes Reduce Our Chances of Being Audited?
By ChiroCode | Published June 16th, 2016 - Last Review/Update March 5th, 2019
Q&A: If we use low level codes on each visit (such as 98940, 99212, 99202), will our chances of being audited be less than if we billed higher level codes?
June 15th, 2016
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
June 7th, 2016
Q/A: Do you Have any Recommendations for Audit Prevention?
By ChiroCode | Published June 7th, 2016 - Last Review/Update March 5th, 2019
Q: Do you have any recommendations for audit prevention?
May 26th, 2016
Groupon: Is it worth the risk?
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published May 26th, 2016 - Last Review/Update March 5th, 2019
Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful.
So what will that mean to you and your practice? It isn’t pretty.
May 19th, 2016
Your Reasons to Delay Compliance Implementation are GONE!
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published May 19th, 2016
ChiroCode has proudly served chiropractic for more than 30 years and continues to work to bring the most necessary, affordable, and user friendly products and services to practices. Increased regulation has hindered practices by creating uncertainty around the nature of guidelines and the expensive penalties that arise from non-compliance with ...
April 30th, 2016
Phase 2 of OCR HIPAA Audits Begins
By Wyn Staheli, Director of Research | Published April 30th, 2016
Phase 2 of HIPAA audits have begun. What do you need to know?
April 28th, 2016
Q&A: What is a Program for a Systematic Approach to Becoming Compliant?
By ChiroCode | Published April 28th, 2016 - Last Review/Update March 5th, 2019
What is a comprehensive program for a systematic approach to becoming a compliant office?
April 28th, 2016
An Important Rule that You're Probably Not Following
By ChiroCode | Published April 28th, 2016 - Last Review/Update March 5th, 2019
The HIPAA Security Rule requires that covered entities (your practice) conduct a Security Risk Assessment (SRA) for your organization, at a minimum of once per year. It is critical that practices perform the Security Risk Assessment for multiple of reasons. Not only is it important to comply with rules and regulations, but also, for what you may consider to be a more motivational reason, to protect your practice (and bank account) from what could become disabling fines and penalties.
April 13th, 2016
CMS Releases Core Quality Measures for 7 Specialties
By Wyn Staheli, Director of Research | Published April 13th, 2016
On February 16, 2016, CMS, in conjunction with major commercial health plans and physician groups, released the first set of core measures, which will be used as the basis for quality-based payments. Part of the MACRA - SGR repeal was to begin to implement payment systems based on quality measures rather than the previous PPS system. This announcement marks the beginning of this process.
April 13th, 2016
Lack of Business Associate Agreement (BAA) Costs Non-Profit 1.55 Million
By Wyn Staheli, Director of Research | Published April 13th, 2016
Failure to have a properly executed Business Associate Agreements (BAA) costs one organization $1.55 Million. In today's highly technological environment, it is too easy to skip the necessary precautions and easy for electronic devices to get lost or stolen. Are you prepared?
April 6th, 2016
HIPAA Violations - The Process Is The Answer
By Instacode Institute | Published April 6th, 2016
It's not just the names and addresses that matter -- It's the compliance. If you can demonstrate that you are hleping yourself to maintain HIPAA compliance by careful documentation and proper procedures, you can go a long way toward avoiding being fined by the HIPAA squads.
Complete & Easy HIPAA Compliance is a clear, simple “Just help me do what I have to do!” workbook that contains all the things the designated security officer must do to instantiate a robust HIPAA compliance program. It comes complete with over 45 forms and letters which can be used to state the office policies, spell out procedures, and ensure that each patient will be protected in their rights under HIPAA policy. It also can help demonstrate that a compliance program is in progress.
April 5th, 2016
Voluntary Disclosure - Look Before You Leap
By ChiroCode | Published April 5th, 2016
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
March 16th, 2016
Protected Health Information De-Identification Standards
By Instacode Institute | Published March 16th, 2016 - Last Review/Update January 27th, 2017
This article contains detailed information on the OCR guidance regarding the de-identification of Protected Health Information (PHI). Avoid HIPAA violations and learn specifically what de-identification is.
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
March 4th, 2016
Guidance For Modifier 24 Usage
By Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016
NAMAS Weekly Auditing and Compliance Tips Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record...
February 24th, 2016
Employee Exclusions Screenings Must be High Priority
By Wyn Staheli | Published February 24th, 2016
Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. This article has important information for organization to ensure compliance.
February 15th, 2016
Unified Program Integrity Contractors (UPIC)
By InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
February 11th, 2016
What are the Rules for Safeguarding Patient Records?
By ChiroCode | Published February 11th, 2016 - Last Review/Update March 5th, 2019
Secure medical records is a broad topic that should be addressed in detail by all practices. There are multiple items to consider when meeting standards to best safeguard protected health information (PHI).
February 1st, 2016
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
February 1st, 2016
Medicare -To Participate or Not!
By | Published February 1st, 2016 - Last Review/Update February 18th, 2016
What are the reasons for looking into Medicare as a dentist? You do have choices, pick the best option for your office.
January 29th, 2016
What is MIPS?
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
January 6th, 2016
EMRs - Coding and Compliance Concerns
By | Published January 6th, 2016
The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act of 2009,...
December 21st, 2015
Review Incident - To for Compliance
By Aimee Wilcox, MA CST CCS-P | Published December 21st, 2015
If your organization performs incident-to services, be sure to perform a periodic review of the rules that govern incident to and then compare them to the practices of your providers to ensure they would pass an audit. Here are just a few of the guidelines that should be reviewed; however, ...
November 9th, 2015
OSHA Recordkeeping Rule Updated
By InstaCode Institute | Published November 9th, 2015
Many healthcare providers are unaware that they are obligated to adhere to all OSHA rules and regulations relevant to their place of business. This includes safety plans and reporting of injuries. New record keeping rules went into effect on January 1, 2015. As part of the new ruling, an online reporting ...
August 19th, 2015
Discharge of an Employee
By | Published August 19th, 2015
Q: Our office has recently had to let an employee go that had been here for a long period of time. What would you recommend to us to ensure we have handled this properly?
A: Not having any information of the circumstances, here are a few general recommendations for you to ...
August 19th, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
August 10th, 2015
Alphabet Soup for Waste and Fraud Inspectors
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
The following are some of the acronyms you would need to know when communicating with auditors:
National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.
Medically Unlikely Edits (MUE): Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.
Office of the ...
August 10th, 2015
Appointments, Reminders, Text Messaging, and HIPAA
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
As more and more people are using mobile and wireless devices, a new term - mHealth - has emerged. According to a National Institute of Health consensus group, mHealth is “the use of mobile and wireless devices to improve health outcomes, healthcare services and health research.” Historically, the biggest gaps and HIPAA violations have been linked to ...
April 24th, 2015
Have you been excluded from Medicare?
By Dr. Chris Andersn | Published April 24th, 2015 - Last Review/Update June 9th, 2016
Compliance is an issue that you should look at as an expedition rather than an endpoint. Board complaints can be a terrifying ordeal, especially if you don’t keep up on compliance in your clinic. Board complaints are something that you have to expect to happen but you can turn that ...
April 9th, 2015
G0105 - Colorectal Cancer Screening; Colonoscopy on Individual at High Risk
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 9th, 2015 - Last Review/Update August 8th, 2017
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). ...
February 26th, 2015
Avoiding Medicare and Medicaid Fraud and Abuse
By | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Recently, the U.S. Department of Health and Human Services Office of Inspector General updated their booklet, “Avoiding Medicare and Medicaid Fraud and Abuse.”
In this publication, the Government agencies, including the Department of Justice, the Department of Health and Human Services office of Inspector General, and the Centers for Medicare and ...
February 9th, 2015
Encryption
By Wyn Staheli, Director of Research | Published February 9th, 2015 - Last Review/Update June 9th, 2016
How secure is your computer? Do you have a password on your computer? Do you have the automatic log offs turned on? Is your computer encrypted? Are your off-site storage files encrypted?
This document is designed to give some basic information about making your office a little more secure. It is not ...
February 3rd, 2015
PPACA Provider Non-Discrimination FAQ
By | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
The following information (emphasis added) is from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
Provider Non-Discrimination PHS Act section 2706(a), as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against ...
January 23rd, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By | Published January 23rd, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses ...
January 9th, 2015
What NOT to Ask Candidates in a Job Interview
By | Published January 9th, 2015 - Last Review/Update January 30th, 2017
Conducting a job interview for potential new employees is a common occurrence, yet is often done in a manner of disorganization. Employers are frequently asking questions that shouldn't be asked and neglecting to ask those questions that may be more essential for conducting a proper interview. Federal and state laws ...
December 30th, 2014
Understanding TOS Discounts and DMPOs
By | Published December 30th, 2014 - Last Review/Update March 9th, 2016
Time-of-Service (TOS) discounts are a common occurrence in chiropractic. What is often assumed is that if insurance isn't involved, there are no rules that apply.
Unfortunately, this is a myth that can become costly to practices and damage provider/patient relationships. So read on to learn the facts about TOS discounting and ...
December 19th, 2014
Compliance Program - What are the Requirements to Implement an Effective Program
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
All sponsors are required to adopt and implement an effective compliance program,which must include measures to prevent, detect and correct Part C or D program noncompliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures and Standards of Conduct;
2. Compliance ...
December 15th, 2014
OIG Reports Success in Efforts to Prevent Fraud, Waste, and Abuse
By | Published December 15th, 2014 - Last Review/Update January 30th, 2017
The HHS OIG Work Plan for the 2015 Fiscal Year has recently been released. In this publication, the OIG addresses the accomplishments made from the previous year's Plan as well as the objectives that will be of interest for the coming new year. Accomplishments for the 2014 Fiscal Year are ...
December 4th, 2014
OASIS Data to be Submitted via Assessment Submission and Processing (ASAP) System Effective Jan 1, 2015
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Effective January 1, 2015, OASIS assessment data will be submitted to CMS via the national OASIS Assessment Submission and Processing (ASAP) system. With the implementation of the OASIS ASAP system, Home Health Agencies will no longer submit OASIS assessment data to CMS via their state databases. To access the ...
November 21st, 2014
Establishing a Multi-Disciplinary Practice and Being Legal
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Q: How do you add another provider type such as a Nurse Practitioner to your practice to provide additional services to patients and legally bill for those services under their license?
A: Multi-disciplinary practices are under scrutiny at the moment by ZPIC, CMS and State Boards. For your reference, just below, there ...
November 19th, 2014
Getting Ready for 2015
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, I have listed some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees:Â Fee ...
November 19th, 2014
Understanding ZPIC
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
November 19th, 2014
Understanding RAC
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
November 17th, 2014
Conducting a Gap Analysis for Your Documentation & Billing Systems
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 17th, 2014 - Last Review/Update January 30th, 2017
What is a Gap Analysis?
A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. This ...
November 17th, 2014
Social Media and Healthcare: Unprofessional Conduct and What It Can Cost
By | Published November 17th, 2014 - Last Review/Update January 30th, 2017
In this electronic age, Social Media has quickly become a very successful tool used for advertising/marketing, communication of various topics and reaching readers and networks beyond our wildest dreams. These networks are often leading to various opportunities or other positive occurrences that we may not have otherwise experienced. Social Media ...
October 24th, 2014
Q & A: Is it a HIPAA Violation to Email Patients?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 24th, 2014 - Last Review/Update January 30th, 2017
Straight from the Office of Civil Rights:
Q: Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?
A: Yes. The Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply ...
October 16th, 2014
Is Compliance a Dirty Word?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
October 16th, 2014
The Role of Statistical Analysis in Fighting Fraud
By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017
It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.
October 6th, 2014
OSHA - Hazard Communication Standard Final Rule (Globally Harmonized System)
By | Published October 6th, 2014 - Last Review/Update January 30th, 2017
The Hazard Communication Standard in 1983 gave workers the "right to know," but the new Globally Harmonized System gives workers the "right to understand."
What you need to do and when:
Chemical users: Continue to update safety data sheets when new ones become available, provide training on the new label elements and ...
October 3rd, 2014
Good Attorneys and Bad Attorneys
By | Published October 3rd, 2014 - Last Review/Update January 27th, 2017
A “good” lawyer could be a “bad” lawyer when it come to your unique problem(s). Never ask or expect any professional person (doctor or lawyer) to perform beyond their scope of practice or ability. A college law degree and passing the state bar, is only a license which permits them ...
October 2nd, 2014
OSHA- Hazard Communication Standard Final Rule (Globally Harmonized System)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 2nd, 2014 - Last Review/Update January 30th, 2017
The Hazard Communication Standard in 1983 gave workers the "right to know," but the new Globally Harmonized System gives workers the "right to understand."
What you need to do and when:
Chemical users: Continue to update safety data sheets when new ones become available, provide training on the new label elements and ...
September 26th, 2014
Patient Electronic Access Tipsheet - Measure Compliance
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 26th, 2014 - Last Review/Update January 30th, 2017
MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective
Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in ...
September 25th, 2014
Healthcare Fraud Investigations in FY 2013
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 ...
September 11th, 2014
According to HIPAA, who are my Business Associates?
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published September 11th, 2014 - Last Review/Update January 30th, 2017
Providers work with many different groups and many of them have some interaction with Protected Health Information (PHI). In an effort to help us understand who qualifies as Business Associates the Department of Health & Human Services has provided some resources.
But first … what is PHI or individually identifiable health information? ...
September 9th, 2014
Compliance Specialists
By | Published September 9th, 2014
Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...
August 29th, 2014
Who in the World are my Business Associates?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 29th, 2014 - Last Review/Update January 30th, 2017
The associates in the provider’s world and healthcare society are filled with loads of potential business associates and endless Individual identifiable health information.
 We have had so many questions about business associates I thought I would go to the source and put together some information from HHS.gov, otherwise known as U.S. ...
May 28th, 2014
OSHA Penalty Calculation Information
By Wyn Staheli, Director of Research | Published May 28th, 2014 - Last Review/Update January 25th, 2017
This article contains information from OSHA which outlines the penalty structure for OSHA violations. It includes a list of different types of violations that may be cited and the penalties that may be proposed by the area director. Also listed are additional violations for which citations and proposed penalties may be issued upon conviction.
These are the types of violations that may be cited and the penalties that may be proposed
March 18th, 2014
How can I make sure new hires have not been in trouble with Medicare?
By Christopher Anderson, DC MCS-P | Published March 18th, 2014 - Last Review/Update January 25th, 2017
To avoid liability, it is recommended to routinely check (every 3 months) the LEIE to ensure that new hires and current employees are not on the excluded list.
One of the many parts of the compliance program is to see if your current staff (including yourself, regular staff and associate doctors) have been placed on the OIG (Office of the Inspector General) List of Excluded Individuals and Entities (LEIE).
OIG has the authority to exclude individuals and entities from Federally funded health care programs and maintains a list (List of Excluded Individuals and Entities or LEIE)of all currently excluded individuals and entities. Anyone who hires an individual or entity on the LEIE may be subject to monetary penalties.
It’s as simple as 1…2…3..
Read More
February 19th, 2014
Are Text Messages HIPAA Compliant?
By | Published February 19th, 2014 - Last Review/Update January 27th, 2017
As more and more people are using mobile and wireless devices, a new buzzword has emerged: mHealth. According to a National Institute of Health consensus group, mHealth is "the use of mobile and wireless devices to improve health outcomes, healthcare services and health research." Historically, the biggest gaps and HIPAA violations ...
February 12th, 2014
EHR Hardship Exemption
By | Published February 12th, 2014 - Last Review/Update January 27th, 2017
The following information is from the Centers for Medicare & Medicaid Services (CMS) regarding the Electronic Health Records (EHR) payment reduction hardship exemption.
September 30th, 2013
Are You Compliant with the New HIPAA Regulations?
By | Published September 30th, 2013 - Last Review/Update January 27th, 2017
September 23rd, 2013 was the deadline for HIPAA Omnibus Final Rule compliance. It seems to have just snuck up on everybody. ChiroCode has spoken with some clincis who say that they don't need to worry about it because ”they are just a small practice.” Please, do not wait any longer to ...
September 24th, 2013
Federal Health Care Fraud Summary 2012
By | Published September 24th, 2013 - Last Review/Update January 27th, 2017
Be aware of the possible monetary results and enforcement actions imposed for fraud. This is the annual report of the Department of Justice Health Care Fraud and Abuse Control Program for FY 2012
September 6th, 2013
Ominbus Final Rule and BAA Contracts Deadline
By | Published September 6th, 2013 - Last Review/Update January 27th, 2017
The official deadline for HIPAA covered entities to reach compliance with the provisions of the Omnibus Rule is officially set as September 23, 2013. This date is right around the corner and as a result, providers are concerned about meeting this deadline. The definition for a business associate has been ...
September 29th, 2012
Privacy Rule De-Identifiers
By | Published September 29th, 2012 - Last Review/Update January 27th, 2017
The HIPAA Privacy Rule provides two ways to de-identify information, which are listed here with the 18 de-identifiers.
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