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Showing 11 posts tagged Centers for Medicare & Medicaid Services.

Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough

It may seem like hair-splitting, but including the wrong diagnostic codes for malnutrition on hospital inpatient claims – using codes for severe malnutrition in place of other forms of malnutrition – is a costly mistake. The estimated overpayment as a result of these coding errors is a reported $1 billion. Because the payment error rate was so high at a colossal 31%, Medicare-Severity Diagnosis Related Group ("MS-DRG") applicable entities must take note and prepare for a marked increase in Department of Health and Human Services Office of Inspector General ("OIG") audits for these coding practices. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims. The increased payer audits will result in severe financial damage for hospitals and other MS-DRG applicable entities if they do not mitigate coding and documentation risks. More >

CMS Suspends the Advance Payment Program and Reevaluates Accelerated Payments

On April 26, 2020, the Centers for Medicaid & Medicare Services (CMS), announced that the Advance Payment Program for Part B suppliers was ending immediately and that the amounts being paid under the Accelerated Payment Program will be reevaluated. Going forward, new applications for the Advanced Payment program will not be accepted.  There are interesting implications and questions for providers who received funds under this program going forward as CMS has not issued any guidance concerning how this will be handled. More >

Coronavirus: Section 1135 Waivers Bring Relief to Healthcare Providers

Invoking powers under the National Emergency Act and the Stafford Act on March 13, 2020, the President declared a national emergency, which, in turn, authorized the Secretary of Health and Human Services to waive conditions of participation requirements for payment for healthcare providers through waivers provided under Section 1135 of the Social Security Act.  The 1135 waivers do not replace 1115 waivers that require states to individually submit requests for waiver of selected Medicaid requirements, but the 1135 waivers are designed to temporarily give healthcare providers more flexibility in providing services during the pandemic crisis. The 1135 waiver is very helpful but does not address all situations or answer all questions, and it creates ambiguity in certain circumstances.   More >

Kentucky Hospitals - Need Additional Acute Care Beds? It Can be Done

Given the recent predictions for an increase in the need for access to additional acute care beds, Kentucky hospitals have the option to seek emergency approval from the Kentucky Office of Inspector General's Division of Certificate of Need for operating these beds. The process is relatively simple, but requires affidavits that meet regulatory specifications. More >

A New Opportunity: Centers for Medicare and Medicaid Services Recognizes the Full Potential of Ambulance Crews and Services

In mid-February 2019, the Centers for Medicare and Medicaid Services (“CMS”), Innovation Center and the Department for Health and Human Services (“HHS”) announced a ground-breaking payment and medical services initiative for ambulance providers called “Emergency Triage, Treat and Transport” (the “ET3”). This new model is the first step in allowing providers of Emergency Medical Services to finally “take off the gloves” to fully utilize both their medical skills and unique patient knowledge to implement a more efficient and effective care model. More >

CMS Executes About-Face on Pre-Dispute Arbitration Ban

The Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule on June 5, 2017, that serves as an effective course reversal on pre-dispute arbitration agreements in a long-term care (“LTC”) setting. This caps off an effort by many in the healthcare and nursing home industry to stop the prior rule, which banned such agreements, from taking effect. More >

"Incident to" Billing - Easy to Get Wrong

Billing for medical services is never easy. Despite attempts by the Centers for Medicare & Medicaid Services (“CMS”) to simplify the rule regarding “incident to” billing for Medicare services, it remains misunderstood by a large swath of providers. This proves problematic, as incorrect billing practices may lead to overpayments and False Claims Act violations. Billing for “incident to” services is an important mechanism to reflect the actual value of mid-level services provided under the specific plan of a physician. When properly followed, the “incident to” rules allow physicians to bill for services provided by non-physician practitioners as if they were performed by the physician at physician reimbursement rates. Additionally, the non-physician provider can be an employee, an independent contractor or even a leased employee, provided that they are supervised by a physician and the requirements are met. Because of the confusing nature of allowing a physician to bill for services he or she did not directly provide to the patient, serious landmines exist that can create problems if the rules are not scrupulously followed and documented. More >

ALERT – ACA Section 1557 Now in Effect – Is your rural health clinic in compliance?

On October 16th, Section 1557 of the Affordable Care Act (“ACA”) went into effect, requiring all recipients of money from federal health care programs to provide language assistance for individuals with Limited English Proficiency at no cost. This section applies to rural health clinics (“RHCs”) as well, which means they must now comply with notice and assistance regulations as well as grievances in the cases of larger entities.  More >

Implied False Certification - Supreme Court Upholds New False Claims Act Standard

While the news for healthcare practitioners regarding regulatory liability under Federal law had largely been positive as of late, the Supreme Court of the United States upheld a new standard of liability under the False Claims Act in the case of Universal Health Services v. United States ex rel. Escobar. The standard of liability approved by SCOTUS is referred to as “implied false certification” and the implications for healthcare providers are numerous. More >

CMS Issues Proposed Rule to Cast a Wide Program Integrity Net

On March 1, 2016, the Centers for Medicare & Medicaid Services (“CMS”) quietly issued a proposed rule that would give the agency far-reaching tools in the area of program integrity enforcement. On its face, the Rule addresses enrollment and revalidation reporting requirements for Medicare, Medicaid and CHIP, but it also significantly increases its authority with regard to the denial or revocation of providers’ Medicare enrollment. More >

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