tci Medicare Compliance & Reimbursement - 2007 Issue 37
COMPLIANCE: Prepare For A Whole New Set Of Denials In January
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Article Overview
This compliance article discusses an upcoming expansion in Medicare medically unlikely edits and how it may affect claim denials starting in January. It is aimed at physicians, coders, and billing staff who need to understand the general direction of the edits, the role of CMS and specialty groups, and why denial review and explanation-of-benefits monitoring matter. The article also addresses concerns about public access to edit lists, the use of modifiers, and the broader compliance implications for claims involving unusually high unit counts.
Why This Topic Matters
It helps revenue cycle and coding professionals anticipate a new category of Medicare denials and prepare for more careful claim review and denial follow-up.
What You Will Learn
- How medically unlikely edits are changing in scope
- Why the upcoming edits matter for claim denials
- How CMS and specialty groups are involved in the policy change
- What compliance staff should look for on explanations of benefits
- Why public access to edit lists is a compliance concern
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Compliance professionals
- Revenue cycle teams
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