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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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 Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey. Additionally, a statewide ban covering additional programs, Medicaid and Children’s Health Insurance Program (CHIP, was also announced.

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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 in the article that follows.

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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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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 the Medicare contractors that review and process enrollment applications, to deny applications from providers ineligible to participate with Medicare.

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Chiropractic Billings Under Government Scrutiny Again

Consistently over the years the Office of Inspector General (OIG) has targeted chiropractic services for audits. In fact, chiropractic services appear annually on the OIG’s workplan agenda. In September 2015, the OIG issued a report recommending that the Centers for Medicare & Medicaid Services’ (CMS) establish better controls and measures to prevent questionable payments, collect overpayments based on inappropriately paid claims and ensure that claims are paid only for Medicare-covered diagnoses.

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Part B Ambulance and Home Health Agencies Moratoria Extended in Parts of NJ

The Centers for Medicare & Medicaid Services (CMS) recently announced another six month extension of moratoria on new home health agencies, home health agency sub-units, and Part B ground ambulance suppliers in certain locations throughout the country.

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CMS and AMA Address Physicians’ ICD-10 Concerns

In a welcomed move, the Centers for Medicare & Medicaid Services (CMS) and American Medical Association (AMA) announced elimination of certain sanctions and penalties during ICD-10 transition and the availability of additional resources to help physicians get ready for ICD-10.

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New Rule for Part D Prescribers: Enroll or Opt-Out

Last year, CMS issued a final rule which requires prescribers of Part D drugs to be either enrolled with Medicare or have submitted an opt-out affidavit to their Medicare Administrative Contractor (MAC) in order for a prescription to be eligible for coverage under the Part D program. See 42 CFR § 423.120(c)(5) and (6).

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CMS Begins Implementing Fingerprint-based Background Checks

On August 6, 2014, the Centers for Medicare and Medicaid Services (CMS) began implementing a new fingerprint-based background check requirement for individuals with 5% or greater ownership interest in providers and suppliers that fall into a high-risk category and are either currently enrolled or have pending enrollment in Medicare. This screening process will be conducted in phases and not all entities in the high-risk screening category will be subject to the first phase.

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CMS Extends Freeze On New Home Health Agencies and Ambulances

On July 29, 2014, the Centers for Medicare and Medicaid Services (CMS) announced an extension on the temporary moratoria on new provider enrollment applications as well as on applications adding additional practice locations for Home Health Agencies (and related sub-units) and Part B ambulance suppliers. The temporary moratoria is for an additional six months.

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Inside Look At Healthcare Fraud Prevention Algorithms

On July 30, 2011, the Centers for Medicare & Medicaid (CMS) implemented its new Fraud Prevention System (FPS), which uses predictive analytics technology, similar to that utilized by credit card companies, to move away from the “pay and chase” model to instead detect aberrant or fraudulent billing patterns prior to payment of claims. According to CMS, by fiscal year 2013, CMS was able to take administrative action against 938 providers and suppliers using FPS, saving or preventing $210.7 million in payments.

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Fingerprint Requirement for DMEs and HHAs Goes Into Effect

The Centers for Medicare & Medicaid Services (CMS) announced that it will begin implementing the fingerprint-based background checks for providers and suppliers in certain risk categories.

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HHS OIG Releases 2014 Work Plan

Every year the U.S. Department of Health and Human Services Office of the Inspector General (OIG) publishes a work plan that provides industry stakeholders with insight as to the OIG’s new and ongoing auditing and investigative activities in the upcoming year.

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Referring to DMEPOS Suppliers: The Competitive Bidding Program

Round 2 competitive bidding program (Program) went into effect as of July 1, 2013 in 91 Metropolitan Statistical Areas (MSAs). At the same time, Medicare began the national mail-order program for diabetic supplies. Below we discuss some of the features of the Program and what this may mean for DMEPOS suppliers and those healthcare providers who refer patients for durable medical equipment and supplies.

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Non-Billing Ordering Providers Must Be Enrolled In Medicaid

New York State Medicaid Program posted new applications on April 1, 2013 for non-billing providers that order, prescribe, and/or refer beneficiaries with fee-for-service Medicaid coverage. New Jersey Medicaid required all such providers to be enrolled an “non-billing” providers by Jan. 1, 2013.

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