Medical Payers & Insurance Companies

Find-A-Code uses Usual, Customary, and Reasonable (UCR) fees as established by the Veterans Administration (VA) to help determine the amount paid for inpatient medical services based on the diagnosis and the geographic area. This article addresses information and pricing for facility fees based on Diagnosis Related Groups (DRGs). The UCR rates included in FindAcode.com come directly from the VA and are divided up into varying per diem (daily) rates as defined by the VA. Be aware that different payers may have different payment methodologies as defined by individual contracts

The Office of Inspector General (OIG) recently released a report entitled “Billing for Remote Patient Monitoring in Medicare Analyzing Medical Practices’ Billing Patterns”. Remote physiologic monitoring services (codes 99091, 99453, 99454, 99457, and 99458) were carefully reviewed because of the significant increase from 2023 to 2024 in the number of patients receiving these services (27% increase) as well as a 31% payment increase during the same time period.

RADs with bi-level capability, with or without a backup rate feature, are devices that use a noninvasive interface (mask) to deliver a higher level of airway pressure when the patient inhales compared to when they exhale. A backup rate feature enables the device to provide a prespecified respiratory rate if the patient’s spontaneous respiratory rate decreases below a set number. HMVs deliver a predetermined amount of air with each breath and typically have more monitoring, safety, alarm, and backup power features (such as batteries) than RADs.

In February 2024, HHS published a final rule modifying the Part 2 regulations to implement section 3221 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, to increase coordination among providers treating patients for SUDs, strengthen confidentiality protections through civil enforcement, align certain Part 2 requirements with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security, and Breach Notification Rules, and enhance integration of behavioral health information with other medical records to improve patient health outcomes. The final rule provides the public with the ability to file complaints alleging violations of the Part 2 confidentiality provisions, requires Part 2 programs to provide notification of breaches of Part 2 records, and implements in regulation HHS’s civil enforcement authority, including the potential for civil money penalties for violations of Part 2.

Medicare Part B payments for “incident-to” services are once again under scrutiny by the HHS Office of Inspector General (OIG) who has flagged “incident-to” billing (when services by non-physician personnel are billed under a physician's NPI at full physician rate) as high risk for improper payments and program abuse.

Federal contractors – Recovery Audit Contractors (RACs) and Unified Program Integrity Contractors (UPICs) – have increasingly targeted wound care claims, particularly involving expensive skin substitutes billed under Medicare Part B. In 2023 alone, over $1.6 billion was spent on these products, prompting heightened audit activity from Qlarant, Novitas, and others. This...

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Today, in utilization news, there is a warning to any surgeons who may be reading this – or anyone who works with surgeons. You may see new efforts by the Centers for Medicare & Medicaid Services (CMS) to lower your fees in coming years. We have all heard about...

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