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 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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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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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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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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GAO Report: CMS Needs to Improve Payment Contractors Oversight

A July Government Accountability Office (GAO) report identified deficiencies in the Centers for Medicare & Medicaid’s Services (CMS) oversight of Medicare audit contractors. The GAO Report further bolstered the long standing provider concerns about the auditing process.

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OIG’s New Fraud Alert: Improper Payments From Labs to Docs

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released a special fraud alert (Alert) in June concerning suspect arrangements between laboratories and physicians that raise Anti-Kickback statute (AKS) concerns.

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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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Basis for Medicare Exclusion

The Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) has broad authority to take measures such as excluding providers and suppliers from participating in the Medicare Program in order to protect the program and beneficiaries. There are a number of reasons why exclusions may be imposed and we summarize them below.

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Wading Through The Medicare Alphabet Soup

The Medicare and Medicaid programs provide health insurance for tens of millions of people. According to Centers for Medicare and Medicaid Services (CMS), the Medicare program alone has 47.5 million beneficiaries and, in 2010, had total expenditures of $523 billion. It is not surprising, therefore, that such large programs invite scrutiny from government auditors and

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Investigators Focus on Medicare Plan B Payments in 2012

In the fall of last year, the Office of Inspector General (OIG) for the Department of Health & Human Services (HHS) released its Fiscal Year 2012 workplan which identifies new and already-in progress programs of focus for the OIG.

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