In the proposed CY 2025 Physician Fee Schedule (PFS) published in the Federal Register on July 31, the Centers for Medicare & Medicaid Services (CMS) is soliciting comments on a proposal to revise the Medicare Claims...more
Congress is on its way to extending the stop-gap funding bills into March (and may have already done so by the time you read this). Absent from the legislation to continue funding the federal government is a “doc fix” that...more
On May 19, 2023, Novitas Solutions and First Coast Options sent an email to certain interested parties, with whom they had engaged following the multijurisdictional contractor advisory committee (CAC) meeting explaining that...more
In what passes for neon lights in the regulatory world, CMS said Medicare Advantage (MA) plans must follow the two-midnight rule, its case-by-case exception and the inpatient-only (IPO) list, according to the final 2024 rule...more
Because Medicare and Medicaid claims audit requests can look like routine billing-related correspondence, they can be easy to miss, leading to expensive and potentially catastrophic consequences. Providers, therefore, should...more
On December 19, 2022, the U.S. Government Accountability Office (GAO) released a report titled, “Medicare: CMS Needs to Address Risks Posed by Provider Enrollment Waivers and Flexibilities” (GAO-23-105494). The report...more
The initial article on this subject discussed generally why Medicare providers need to understand the Medicare administrative appeals process, especially in connection with overpayment determinations, Additional Documentation...more
With many hospitals well into their FY 2021 Medicare cost report preparation, here is a brief reminder of the process required for protesting items, as well as a summary of two new developments for Medicare Graduate Medical...more
The Centers for Medicare & Medicaid Services' (CMS) FY 2022 Budget Justification request to Congress suggests an increased focus on Medicare claim reviews and an effort to decrease the number of claim denials overturned...more
Medicare pays billions of dollars in fraudulently billed claims each year despite the various tools the Medicare system has at its disposal. Because of this problem, the Centers for Medicare and Medicaid Services (“CMS”)...more
On December 3, 2020, Centers for Medicare & Medicaid Services (“CMS”) announced key details concerning a new value-based reimbursement and patient care model – the Geographic Direct Contracting Model (the “Model” or “Geo”)....more
Despite many parts of the country seeing upticks in COVID-19 cases and hospitalizations, the Centers for Medicare & Medicaid Services (CMS) is ready to get back to some of its normal oversight activities related to the...more
In the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (2020 OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) established a prior authorization process and...more
On April 21, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Quality, Safety & Oversight memorandum QSO-20-27-Hospital (QSO Memo), addressed to state survey agencies to provide guidance to independent...more
On March 28, 2020, the Centers for Medicare & Medicaid Services (“CMS”) announced that the agency would provide relief to Medicare providers and suppliers by expanding the Accelerated and Advance Payment Program for the...more
On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance expanding its Accelerated and Advanced Payment Program, which now allows most Medicare Part A and Part B providers and suppliers to...more
Report on Medicare Compliance 29, no. 7 (February 24, 2020) - Guardian Elder Care Holdings Inc., which operates more than 50 skilled nursing facilities (SNFs) in Pennsylvania, Ohio and West Virginia, and its related...more
Report on Medicare Compliance 29, no. 5 (February 10, 2020) - At least two Medicare administrative contractors (MACs) have set their sights on observation services, and there may be more to come. WPS is auditing...more
On August 17, 2018, the Centers for Medicare and Medicaid Services (CMS) issued the FY 2019 Medicare IPPS final rule. Part of the rule modified the supporting documentation required under 42 CFR 413.20 to be submitted with...more
This past week, CMS confirmed it will continue the 2018 and 2019 underpayment policy for certain 340B covered entities unless the D.C. Court of Appeals upholds the lower court’s ruling that it is unlawful. In that case, CMS...more
On April 12, 2019, CMS released a Medicare Learning Network Matters article (MLN) in connection with Change Request (CR) 11042, which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29 – Appeals of...more
CMS recently issued a Medicare Learning Network (MLN) Matters article in connection with Change Request 11042 released on April 12, 2019 (the Change Request), which revises the Medicare Claims Processing Manual (Publication...more
Last week, CMS announced on its website that for cost reporting periods beginning on or after October 1, 2019, providers must comply with a so-called “longstanding” rule to claim reimbursement for crossover bad debts from the...more
While many Medicare providers and suppliers may not yet have experienced a Targeted Probe and Education (TPE) audit, they should be on the lookout for this newest weapon in the medical review arsenal. It is important that...more
On September 12, 2018, the U.S. House of Representatives approved by voice vote four bipartisan bills to amend various provisions of the Medicare program. A summary of each bill is below....more