MACRA Explained: New World of Medicare Reimbursement

Many healthcare providers and suppliers cheered when Congress did away with the sustainable growth rate (SGR) formula by passing the Medicare Access and CHIP Reauthorization Act (MACRA). No longer did they have to worry on an annual basis if a patch to prevent double digit cuts to reimbursement will be passed. But a new reimbursement methodology under MACRA leaves many practitioners wondering if they will meet the metrics or face payment cuts. 

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Section 1557 – ACA’s New Non-Discrimination Final Rule

The Office of Civil Rights (OCR) within the U.S. Department of Health and Human Services, recently issued a Non-discrimination in Health Care Programs and Activities rule. This final rule implements Section 1557 of the Patient Protection and Affordable Care Act (ACA). Section 1557 builds on existing civil rights laws and prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities and applies broadly to many providers and suppliers.

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Overpayment Audit: Medicaid is Serious About Excluded Providers

Under the Affordable Care Act (ACA), providers and suppliers who bill for services furnished by an excluded or an unlicensed person are considered to have received an overpayment from Medicare which must be reported and returned within 60 days of “identifying” the overpayment (claims-based overpayment). New Jersey Medicaid recently reminded providers that a similar requirement for Medicaid and Medicaid Managed Care providers exists in New Jersey and will be enforced. 

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Warning: Medicare Contractors Enforcing Fingerprint Requirements

The passage of the Patient Protection and Affordable Care Act (ACA) heralded a new era for provider enrollment and revalidation by enhancing provider and supplier screenings. The Centers for Medicare & Medicaid Services (CMS) now requires certain providers to be fingerprinted in order to continue participating in the Medicare program. Medicare contractors (MACs) have been sending notices to impacted providers and suppliers advising them to complete fingerprinting within a specified time-frame.

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Out-of-Network NJ Cardiologist Wins a Case Against Aetna

A recent decision by a New Jersey Appellate Court confirmed an out-of-network provider’s right to collect from an insurance company for emergency services he rendered to patients covered by the insurance company. 

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CMS Announces Moratoria on Non-Emergency Ground Ambulance Suppliers in Parts of NJ

In a recent federal register publication the Centers for Medicare & Medicaid Services (CMS) announced the extension of temporary moratoria already in place on the enrollment of new Medicare Part B nonemergency ground ambulance suppliers and Medicare home health agencies (HHAs), subunits, and branch locations in specific locations within designated metropolitan areas in New Jersey, as well as Florida, Illinois, Michigan, Texas, and Pennsylvania. Additionally, a statewide ban for these providers and suppliers, which now also extends to not only Medicare but also Medicaid and Children’s Health Insurance Program (CHIP), was also announced.   

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Medicaid Enrollment For Providers Got Tougher, But Many States Lack Enhanced Screening

The Affordable Care Act (ACA) heralded a new era of provider enrollment screenings not only in the Medicare program but also in States’ Medicaid programs. A series of new Office of Inspector General (OIG) reports reviewed the effectiveness of the States’ implementation of the new screening requirements in the Medicaid programs and found areas in need of improvement.

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CMS Implements Home Health Pre-Claim Review in 5 States

The Centers for Medicare & Medicaid Services (CMS) recently launched a demonstration project that will initiate a pre-claim review for home health services. The project seeks to lower a nearly 60 percent claims error rate stemming largely from insufficient documentation.

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Latest Medicare and Medicaid Provider Program Updates

Healthcare practitioners should be aware of important updates and changes to Medicare and Medicaid Programs of New York and New Jersey. We summarize some of these changes changes below.

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Medicare Enrollment Screening Tools Reviewed By OIG

The Centers for Medicare & Medicaid Services (CMS) views the enrollment process as an important gatekeeping tool for preventing fraud, waste and abuse. The passage of the Affordable Care Act (ACA) enhanced the ability of CMS to further this goal. Recently, the Office of the Inspector General (OIG) published a report analyzing the effectiveness of certain enhanced provider enrollment screenings.

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Healthcare Providers Beware: Failure to Pay State Tax Could Lead to License Suspension

On May 16, 2016, a new rule went into effect that empowers the New Jersey Division of Taxation Director (Director) to notify a licensing State agency that a license issued by the agency to conduct a profession, trade, business, or occupation should be suspended where a license holder fails to pay a State tax indebtedness.

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New Reimbursement Rates for Labs Go Into Effect in 2017

The passage of the Protecting Access to Medicare Act (Act) of 2014 ushered in a new era for Medicare laboratory reimbursement rates not seen in three decades. 

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Proposed New Regulations Impacting NJ Dentists and Hygienists

The New Jersey State Board of Dentistry (Board), which licenses and oversees dentists and hygienists in the State, has recently proposed new regulations that will impact how hygienists and dentists practice. 

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NY Electronic Prescribing: Blanket Waivers Issued

Just days after the new e-prescribing rules went into effect, New York’s Commissioner of Health has issued ten blanket waivers that lift electronic prescribing requirements under exceptional circumstances. The waivers will be effective for a year, until March 26, 2017, when the Commissioner will re-evaluate provider and software feasibility and preparedness.

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Latest Medicare Changes That Will Impact Your Practice

The Centers for Medicare & Medicaid Services (CMS) has issued number of recent updates to the Medicare program which impact various providers and suppliers. 

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Providers Beware: Medicare Proposes Harsh New Screening Requirements

The Centers for Medicare & Medicaid Services (CMS) has once again proposed new rules which would enhance the screening requirements for providers and suppliers. The rule proposals would ratchet up the scrutiny on provider enrollments and toughen suspension and revocation penalties.

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OIG 2016 Workplan: Is It Time To Check Your Compliance?

Every year the Office of the Inspector General (OIG) issues a workplan that identifies the agency’s planned audit activities for the upcoming year. The workplan offers valuable information for healthcare entities by providing them with an opportunity to conduct appropriate risk assessments, and, where indicated, to modify the entity’s compliance program.

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CMS Documentation Reminder to Physicians Ordering Lab Services

Recent results from the Comprehensive Error Rate Testing (CERT) Program revealed that the majority of improper payment for laboratory service result from insufficient documentation.  This article summarizes important documentation recommendations from CMS.

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Which Providers Cannot Enroll in Medicare?

Each year certain providers attempt to enroll in the Medicare program to participate and bill for services. The Centers for Medicare & Medicaid Services (CMS), however, instructs its contractors that review and process enrollment applications, to deny applications from certain providers ineligible to participate with Medicare.

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Closing a Pharmacy? Remember to Follow Specific Steps

When closing a New Jersey pharmacy certain steps should be followed to protect patient access to medication and records and to minimize the disruption to continuity of care. 

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