Medical Billing News
Welcome to Medical Billing News from AdvantEdge. As we all know, medical coding and billing have many moving parts that evolve every day. Here we highlight items of particular importance for physician billing, practice management and proper reimbursement for physicians, ASC’s and hospital providers.
Most of the articles here have “tags” to highlight their key topics. You can click on any tag below and immediately get all of the articles on that topic.
For more depth, please see our educational guides:
AHS EHR Incentive Program Manual for 2013
AHS PQRS Resource Guide for 2013
AHS eRx Resource Guide for 2013
RI – BCBSRI – Implements New Medical Policy for Home and Facility-based Sleep Testing
5/20/2013 – On May 1, 2013, BCBSRI implemented a new medical policy for home and facility-based sleep testing. (HST) HST will now be a covered benefit for all BCBSRI members. Preauthorization for facility-based sleep tested will be recommended for all their Commercial and BlueCHip for Medicare Plans. For more information, providers should contact the [...]Tags: Medical Billing
MA – BCBSMA Begins Sleep Management Program on July 1, 2013
5/20/2013 – BCBSMA will begin their Sleep Management Program on July 1, 2013. The program will be administered by AIM Specialty Health. All clinicians who request prior authorizations for sleep studies or sleep durable medical equipment and supplies will need to be registered with AIM in order to request authorizations. Provides may [...]Tags: Medical Billing
NY – MEDICAID – Revised Policy for Patient Centered Medical Home Incentives
5/16/2013 – Effective July 1, 2013, New York State Medicaid is changing the reimbursement policy and billing requirements for providers recognized as Patient Centered Medical Homes (PCMH) by the National Committee for Quality Assurance (NCQA). The new policy applies to both Medicaid managed care and fee-for-service. The revised policy will now use the 2011 PCMH [...]Tags: Health care Reform, Medical Billing
MA – BMC HealthNet – New Reimbursement Guidelines
5/16/2013 – BMCHP has updated their reimbursement policy for “Evaluation and Management Services.” The changes are as follows and are taken directly from BMC HealthNet’s Newsletter. Effective for dates of service on or after June 1, 2013: 1. When a preventive visit (99381-99397, 99429) and a problem-oriented visit (99201-99380) reported with modifier 25 are [...]Tags: Coding, Medical Billing
RI – BCBSRI has Chosen a New Behavorial Health Partner
5/16/2013 – Effective July 1, 2013, BCBSRI will contract with Value Options as their new partner for behavorial health services. Value Options is an independent behavioral healthcare and wellness company and will support BCBSRI’s holistic approach that bridges “medical care” and “behavioral healthcare”. Contracting with Value Options should help improve coordination of care for [...]Tags: Behavioral Health, Medical Billing
RI – BCBSRI – Laboratory Changes for Medicare Advantage Members
5/16/2013 – Beginning April 1, 2013, BCBSRI will expand their BlueCHiP for Medicare laboratory network from their exclusive arrangement with East Side Clinical Laboratory to a preferred network of laboratory providers. This change will ensure BlueCHiP for Medicare members have more laboratories to choose from. The laboratory network will consist of the following laboratories: [...]UNITEDHEALTHCARE – Echocardiogram Precertification for Neighborhood Health Partnership
5/16/2013 – For service dates on or after July 1, 2013, UnitedHealthcare’s Neighborhood Health Partnership will require the ordering physician to provider precertification for the following outpatient echocardiogram procedure codes: 93303 – Transthoractic echocardiography for congenital cardiac anomalies; complete 93304 - Transthoractic echocardiography for congenital cardiac anomalies; follow-up or limited study 93306 – Echocardiography, transthoracic [...]Tags: Coding, Medical Billing
UNITEDHEALTHCARE – Updates to Facility Outpatient Grouper Mapping
5/16/2013 – Effective July 1, 2013, UnitedHealthcare, after review of the following codes against national guidelines, determined they could be appropriately billed and reimbursed as outpatient procedures in hospitals and ASCs when ordered by a physician. 22548 – Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process. 32096 [...]Tags: Coding, Medical Billing, Surgery Coding, Surgical Billing
PA – PENNSYLVANIA MEDICAID – Updates to Surgical Fee Schedule
5/16/2013 - The Pennsylvania Medicaid bulletin issued on April 15, 2013 announced changes to the Medical Assistance (MA) Program fee schedule. These changes are effective for dates of service on and after April 15, 2013. The Bulletin contains the following changes related to surgical coding. The complete bulletin listing all of the CPT codes [...]Tags: Coding, Medical Billing, Surgery Coding, Surgical Billing
2013 May Bring Hope for SGR Repeal
5/16/2013 – The combination of the Congressional Budget Office (CBO) reducing the cost of the SGR fix from $245 billion to $138 billion, both sides of Congress beginning to address alternative payment methods and medical organizations participating and offering suggestions on those payment methods, may result in replacing the SGR Medicare payment system [...]Tags: Health care Reform, SGR, SGR and Medicare Fee Schedule
CMS Goes Public with Hospital Charge Information
5/15/2013 – On May 8, the federal government shared with the public what hospitals bill Medicare for the 100 most common diagnoses and treatments and well as Medicare’s payments for those treatments. The published file shows the wide variation in charges for these 100 services, which CMS will study to determine the impact this [...]PA – Highmark Acquires West Penn Allegheny Health System
5/15/2013 – On April 29, Highmark, a Pittsburgh-based not-for-profit insurer, announced the creation of Allegheny Health Network by acquiring West Penn Allegheny Health System. Having secured final review and approval from the Pennsylvania Insurance Department , the hospitals and providers of West Penn Allegheny Health System (WPAHS) will now serve as a key [...]FLORIDA MEDICAID – New Medicaid Agreement Forms
5/14/2013 – As of June 1, 2013, the 2012 version of the Medicaid Provider Agreements (Institutional Medicaid Provider Agreement, Non-Institutional Provider Agreement, ICF/DD Medicaid Provider Agreement, and Medicare Crossover Only Medicaid Provider Agreement) will no longer be accepted and will be returned to the provider. All enrolling providers must use the most current version [...]Tags: Medical Billing, Provider Contracting, Provider Enrollment
MA – Tufts Health Plan’s Policy Changes
5/15/2013 – Tufts will initiate the following policy changes, effective July 1, 2013. Corrected Claims, Disputes of Duplicate Claims and Late Charges For commercial claims adjudicated on or after July 1, 2013, corrected claims and provider payment disputes of duplicate claim denials must be received by Tufts no later than 180 days from the [...]Tags: Coding, ICD-10, Medical Billing
AmeriHealth Introduces a New PPO Product
5/14/2013 – AmeriHealth New Jersey has introduced a new 51+ Exclusive Provider Organization (EPO) product, which allows members to receive in-network benefits without selecting a primary care physician or obtaining referrals. However, members must use network providers for all their medical services. There are no out-of-network benefits. Preventive services are covered at 100 percent. Plan [...]Tags: Medical Billing
AmeriHealth & Cooper University Health Care Join Forces
5/14/2013 – A health insurer and a hospital system — AmeriHealth New Jersey and Cooper University Health Care — will be joining forces to offer an expanded suite of health plans and an accountable care model for New Jersey residents. The announcement was made in April that Cooper will acquire a 20 percent [...]Tags: Accountable Care Organizations, ACOs, Health care Reform, Medical Billing
MA BCBS Will Offer Patients New Payment Summary
May 13, 2013 – MA BCBS recently designed a new patient Explanation of Benefits (EOB) named the Summary of Health Plan Payments. The new EOB will be sent to any member who has a balance due on their medical services after BCBSMA has made a payment. BCBSMA states the new EOB is easier [...]Tags: Healthcare Reform, Medical Billing
UnitedHealthcare Will Offer Direct Provider Payment in June
5/13/2013 – UnitedHealthcare has partnered with InstaMed to provide direct online payments for their commercial members. Payments will be made electronically through direct deposit into the providers bank account. Commercial member payments will be facilitated through the myuhc.com member portal and will enable providers to: Collect more patient payments and reduce bad debt Accelerate patient payment [...]Tags: Medical Billing
Humana Offers Benefit Estimator
May 9, 2013 – Humana has joined the ranks of insurance companies offering patients the ability to understand their potential health care costs before receiving medical care. Humana’s new web tool is called Benefit Estimator and it is designed to help health care providers build an estimate of a patient’s payment responsibility, specific to [...]Tags: Health care Reform, Medical Billing
Human Achieves CORE Phase II Certification
5/9/2013 – This article was taken directly from Humana’s website. Humana has received the Committee on Operating Rules for Information Exchange (CORE) Phase II Certification seal. This initiative is part of the Administrative Simplification Compliance Act, which is a part of the federal government’s health care reform. Obtaining CORE Phase II certification means health [...]Tags: Health care Reform, Medical Billing
Humana Offers New Medicare Advantage Plan
May 9, 2013 – In 2013, Humana will continue its plan to connect Medicare Advantage PPO and PFFS members to primary physicians by introducing Humana Prime Choice PPO, a Medicare Advantage (MA) PPO plan that requires the member to select a primary physician. Primary physicians do not necessarily have to be primary care physicians such as [...]Tags: Healthcare Reform, Medical Billing
Aetna Acquires Coventry Health Care
5/9/2013 – On May 7, 2013, Aetna completed the acquisition of Coventry Health Care, Inc., a national managed health care company. This makes Aetna one of the largest health care benefits company in America based on membership as Coventry brings 3.87 million members to Aetna’s 18.3 million membership. Coventry currently offers risk and fee-based [...]Tags: Medical Billing
Obama Releases 2014 Federal Budget – $400 Billion in Health Care Savings
May 1, 2013 – On April 10, 2013, the Obama Administration released its proposed federal budget for fiscal year 2014. The President, dedicated to his commitment to reducing the deficit by $4.3 trillion over ten years, has proposed savings of $400 billion from changes to federal health programs, including Medicare and Medicaid. The Administration [...]CMS Temporarily Delays Ordering and Referring Denial Edits-Phase 2
April 29, 2013 – Last week, CMS announced that Phase 2 of the Ordering and Referring Denial Edits, which was to take place May 1, 2013, has been temporarily delayed due to technical issues. CMS did not mention the technical issues or the new effective date. These edits would have denied medical claims if: the [...]CMS Taking Applications for the 2014 Medicare Shared Savings Program
April 29, 2013 - The application period for an organization to apply for the 2014 Medicare Shared Savings Program (MSSP) begins this May. In order to apply for the program, a Notice of Intent (NOI) must be submitted electronically to CMS along with a CMS User ID. Applications for the MSSP will be taken this [...]CMS Provides Resources for EHR Audits
April 29, 2013 – In 2012, CMS and its contractor Figliozzi and Company, began post-payment audits on Medicare and dually-eligible (Medicare and Medicaid) providers who were participating in the EHR Incentive Programs. In addition to the post-payment audits, CMS began pre-payment audits this year, starting with provider attestation during and after January 2013. These pre-payment [...]CT, NH & NY BCBS – Anesthetic Agents Included in Global Package
On April 1, 2013, Anthem (CT, NH) & Empire (NY) BCBS updated their reimbursement policy to include anesthetic agents in the global surgery package. The surgical package definition in the CPT 2013 Professional Edition indicates local infiltration, metacarpal/metatarsal/digital block or topical methods of anesthesia are included in the surgical package. Anesthetic agents, including, but [...]Tags: ASC Coding, Coding, Medical Billing, Surgery Billing, Surgery Coding, Surgical Billing
UNITED HEALTHCARE – Speech Therapy Policy Revised
April 15, 2013 – In following CMS coding guidelines, UHC’s reimbursement policy for speech language therapists/pathologists is as follows: UHC will reimburse the following CPT codes: 92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 92508 – ;group, 2 or more individuals 92526 – Treatment of swallowing dysfunction and/or oral function [...]CT & NH Anthem BCBS: Bundled Services and Supplies
April 15, 2013 – On April 1, 2013, Anthem BCBS updated their Anthem Online Provider Services (AOPS) website with the following new and/or revised reimbursement policies. Bundled Services and Supplies Anthem’s Bundled Services and Supplies policy includes new 2013 Current Procedural Terminology CPT® codes 99487-99489 (chronic care coordination services) and 99495-99496 (transitional care management [...]Tags: Coding, Medical Billing
UNITEDHEALTHCARE – Changes to Outpatient Cardiology Notification Program
April 15, 2013 – Effective July 1, 2013, a clinical coverage review will be conducted to determine if services are medically necessary once notification of a planned service subject to UnitedHealthcare’s Outpatient Cardiology Notification Program requirements is received. Providers must notify UHC of any planned service subject to UHC’s Notification Program requirements and complete [...]Tags: Coding, Medical Billing, Prior Authorization
UNITEDHEALTHCARE: Speech Therapy Policy Revised
April 12, 2013 – In following CMS coding guidelines, UnitedHealthcare’s (UHC) reimbursement policy for speech language therapists/pathologists are as follows: UHC will reimburse the following CPT codes: 92507 – Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual 92508; group, 2 or more individuals 92526 – Treatment of swallowing dysfunction and/or oral [...]Tags: Coding, Medical Billing
April 12, 2013 – At the end of March and early April, Illinois Medicaid sent out several provider bulletins with information that could affect your practice. Updated Practitioner Fee Schedule - Illinois Medicaid released their Practitioner Fee Schedule effective with service date of 4/1/2013 Primary Care Provider Incentive Program The Illinois Department of [...]
Tags: Health care Reform, Medical Billing
IL – MEDICAID: Medical Payment Remittance Advices
April 12, 2013 – On April 8, the Department of Healthcare and Family Services (IHFS) sent a notice to Illinois providers stating that the IHFS will no longer retain remittance advices that are awaiting payment by the State of Illinois Comptroller’s Office. Remittance advices received by the Department will be prepared and forwarded for mailing distribution. [...]Tags: Medical Billing
PA – HIGHMARK BCBS: Updates Its Authorization List for Outpatient Services
April 12, 2013 – In April and May Highmark BCBS will update its list of outpatient procedures/services requiring authorization. CODES TO BE DELETED: Effective April 15, 2013, Highmark will delete 267 codes from its list of outpatient procedures/services requiring authorization. Click here to view a list of these codes. (Please note, the codes [...]Tags: Coding, Medical Billing, Prior Authorization
IN & OH – Anthem BCBS: New Reimbursement Policy for Use of Modifier 22
April 12, 2013 – Anthem BCBS in Indiana and Ohio (referred to as the Health Plan), have posted a new reimbursement policy titled Modifier 22 (Increased Procedural Services). This policy outlines the Health Plan’s current position today when modifier 22 is appended to a CPT®) or HCPCS Level II code. Modifier 22 is described [...]Tags: Coding, Medical Billing
NJ – HORIZON BCBS – Makes Patient ID Cards Available to Providers Online
April 12, 2013 – Horizon BCBS has now made an online version of patients’ Horizon BCBSNJ card through NaviNet®. This feature has been added to the Eligibility & Benefit Inquiry and allows providers to review and print an image of their patient’s ID card as a temporary proof of coverage in the event [...]Tags: Medical Billing
IL – BCBSIL: Pre-Service Clinical Appeals
BCBSIL will review pre-service clinical appeals if BCBSIL previously denied services that could jeopardize a member’s health or would subject the member to severe pain that cannot be managed without the requested care or treatment. The medical service or treatment should meet the following criteria: Satisfy the above description as urgent in nature Has [...]Tags: Coding, Documentation, Medical Billing
IL – BCBSIL – NDC Pricing to Begin for Professional Claims
April 12, 2013 – Effective with service dates beginning June 1, 2013, BCBSIL will implement NDC (National Drug Code) pricing for professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims, which means that all claims for drugs must include NDC data in order to be accepted for processing by BCBSIL. When submitting NDCs on professional/ancillary [...]Tags: Coding, Medical Billing
CT – ANTHEM BCBS – Some Functionalities Moving Exclusively to Availity® & New Online Provider Forms
April 12, 2013 – Some time ago, Anthem BCBSCT collaborated with Availity to offer a multi-payer portal solution that gives providers secure, single sign-on access to multiple payers’ information. Availity allows access to Anthem eligibility (coverage), benefits, claims status, clinical messaging and Availity® CareProfile® on Availity for free. Availity also offers access to ask [...]Tags: Medical Billing, Provider Enrollment
CT, NH, NY: ANTHEM & EMPIRE BCBS – Reimbursement Policy Updates
April 12, 2013 – As of April 1, 2013, the following new and/or revised updates were added to Connecticut and New Hampshire Anthem BCBS’ and to New York Empire BCBS’ Online Provider Services website. Telemedicine and Telehealth Services Both Anthem & Empire BCBS in their policies dated February 1, 2013, they made coding updates [...]Tags: Coding, Medical Billing
UnitedHealthcare: Changes to Reimbursement for Modifiers 22 and 63
April 11, 2013 – Under UnitedHealthcare’s (UHC) Increased Procedural Services Policy, UHC will pay an additional 20 percent of the allowable amount of the unmodified procedure, not to exceed the billed charges, when the medical record documentation supports the use of the modifiers 22 (increased procedural services) and 63 (procedures performed on neonates and infants up to [...]Tags: Coding, Medical Billing
Cigna No Longer will Offer Second-level Appeals
April 11, 2013 – It has always been Cigna’s policy to offer second-level appeals to health care professionals who were not satisfied with the resolution of a first-level review. However, effective July 1, 2013, Cigna will no longer offer second-level appeals. All appeals will follow a thorough single appeal review process and will [...]Tags: Medical Billing
Bill Introduced to Offer More Meaningful-Use Exemptions
April 11, 2014 – In March, Rep. Diane Black (R-TN) introduced HB1309, the EHR Improvements Act, that would offer more meaningful-use exemptions to those physicians who do not meet meaningful-use targets and could face the 1% cut in Medicare reimbursement in 2015. The crux of her bill would provide a three-year exemption from the [...]Tags: EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use, Medical Billing
CMS Increases Medicare Advantage Rates for 2014
April 11, 2014 – On April 1, CMS announced the final Medicare Advantage (MA) rates for 2014, increasing the rates to 3.3 %. Previously, CMS had proposed a 2.3% reduction in the amount the government pays private insurance companies that provide MA plans. The reduction, which would save the government money but could potentially [...]Tags: CMS Updates, Health care Reform, Medical Billing, SGR and Medicare Fee Schedule
HHS Issues ACA Brochures for Providers and Consumers
4/11/2013 – The Department of Health and Human Services has produced a series of brochures that help consumers and providers understand various provisions of the Affordable Care Act and what it may mean for them. For providers – ‘Top 5 Things Providers Need to Know” Other “Top Five” brochures include: Families with Children ( English [...]Tags: ACA, Accountable Care Act, Affordable Care Act, Health care Reform, Medical Billing
2% Sequestration Cut Now in Effect for Medical Services
April 3, 2013 – The 2 percent Sequestration budget cut was effective beginning with service date of April 1. Providers will likely see the reduction in their Medicare payments beginning in mid-April. The cut will be made to the actual payment and not to the Medicare allowed charge (allowable). As an example, if the [...]Tags: 2013 Medicare Physician Fee Schedule, EHR Incentive Program, Healthcare Reform, Meaningful Use, Medical Billing, Sequestration
CMS’ Medical Neighborhood Program Up-and-Running
4/1/2013 – All fifteen states are now actively participating in the “medical neighborhood” demonstration that is being piloted in 15 communities under a $20.75 million grant from CMS. The last five communities began their training in March. The grant is part of the Health Care Innovation Awards program, a Department of Health and Human [...]Tags: Accountable Care Act, Accountable Care Organizations, ACO, Healthcare Reform
CMS Steps Back from Pushing Stage 3 EHR in 2013
March 28, 2013 – In November, the Office of the National Coordinator for Health Information Technology (ONC) published recommendations for meaningful use Stage 3 requirements to be effective in 2016. During the comment period, which ended on January 14, the AMA, the College of Healthcare Information Management Executives (CHIME) and the Federation of American [...]Tags: ACA, Affordable Care Act, CMS Updates, EHR, EHR Incentive Program, Healthcare Reform, Medical Billing
CMS Redesigns Medicare Summary Notice (Patient EOB)
March 28, 2013 – In early March, CMS announced the redesign of the Medicare Summary Notice (MSN), the statement that informs Medicare beneficiaries about their claims for Medicare services and benefits. The MSN details the services Medicare has or hasn’t covered, provides information about a beneficiary’s payment responsibilities, and lays out the process for [...]Tags: CMS Updates, Medical Billing
CMS Implements Medicare Ordering/Referring Rule on May 1
March 28, 2013 – On May 1, 2013, Phase 2 of CMS’ Ordering/Referring Rule will be implemented causing Medicare claims to deny for providers who furnish services based on orders/referrals that do not meet CMS’ criteria. Claims will now be denied if: the ordering provider’s NPI number and legal name are not on the claim, [...]Tags: ACA, Accountable Care Act, CMS Updates, Healthcare Reform, Medical Billing
Medicare – Outpatient Therapy Alerts for Claims Submitted without G-Codes and Modifiers
March 28, 2013 – As mandated under the Middle Class Tax Relief and Jobs Creation Act of 2012, HHS (Dept. of Health and Human Services) implemented a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services. In November 2012, CMS issued regulations to create [...]Tags: 2013 Medicare Physician Fee Schedule, Healthcare Reform, Medical Billing
CMS Publishes FAQs for Billing Transitional Care Management Services
March 28, 2013 – The 2013 Medicare Physician Fee Schedule adopted the AMA’s new 2013 transitional care management (TCM) CPT codes for non-face-to-face post discharge management services furnished within 30 days of discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial observation to the patient’s community setting (home, domiciliary, rest home, [...]Tags: 2013 Medicare Physician Fee Schedule, CMS Updates, Coding, Medical Billing
MA – BCBSMA Contracts with PAs to be Primary Care Providers
3/26/2013 – This year, BCBSMA will begin contracting and credentialing physician assistants (PAs) and adding them to their listing of providers for their members. Massachusetts law recently broadened the scope of practice of physician assistants, recognizing them as primary care providers. BCBSMA will work with Health Care Administrative Solutions, Inc. (HCAS) to verify credentials [...]Tags: Healthcare Reform, Medical Billing
Aetna Contracts with American Medical Response
3/26/2013 – Aetna has contracted with American Medical Response (AMR) as their national preferred medical transportation provider for all Aetna commercial members. AMR will be a participating provider. Aetna says that members and plan sponsors will see increased savings when they choose AMR over non-participating ambulance services. Aetna signed a three-year agreement with AMR [...]Tags: Medical Billing
NJ, PA – AETNA Allows Direct Transfer of Members from ER & Observation to SNFs
3/26/2013 – Aetna now allows for the transfer of their members from the emergency room (ER) or observation unit directly to a skilled nursing facility (SNF). A hospital stay is no longer required for a direct transfer. The policy applies to both their Medicare Advantage and commercial members. For Medicare Advantage members – MA [...]Tags: Medical Billing
Aetna to Review Clinical Documentation
3/25/2013 – Aetna has instituted a new program that reviews patient medical records to compare the clinical coding to the corresponding clinical services provided to their members. Aetna will base their requests on either: The characteristics of the claim (such as the charges billed in conjunction with the procedure performed). The provider who submitted [...]Tags: Coding, Medical Billing, Surgery Billing, Surgery Coding
AETNA – Issues New Surgical Clinical Policy Bulletins
3/25/2013 – Aetna recently issued new Clinical Policy Bulletins, effective June 1, 2013, for two surgical procedures and an anesthesia service. Hiatal hernia procedures billed with bariatric surgery Aetna will deny hiatal hernia codes (39599,43280,43281,43289 and 49659) when billed with bariatric surgery codes. Modifier 59 (distinct procedural service) may not be applied to [...]Tags: Coding, Medical Billing
AETNA – Issues Cardiopulmonary Clinical Policy Bulletin
3/25/2013 – Aetna recently issued a new Clinical Policy Bulletin (#0825) for cardiopulmonary exercise testing covering only the following diagnosis codes for CPT code 94621 – Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) This policy will become effective June 1, 2013 •162.2–162.9 – Malignant neoplasm of trachea, [...]Tags: Coding, Medical Billing
MA – Tufts Health Plan – Anesthesia Updates
March 21, 2013 – Tufts wants to remind everyone that all anesthesia claims submitted to them must include the appropriate anesthesia modifier to denote whether the service was personally performed by the anesthesiologist or was performed in conjunction with a CRNA. Effective for service dates on or after April 1, 2013, Tufts will reimburse [...]Tags: Anesthesia Billing, Medical Billing
IL – MEDICAID – Sets Up Overpayment Protocol and Provider Enrollment Risk Categories
3/21/2013 – As a result of two Public Acts under the Save Medicaid Access and Resources Together (SMART) Act, Illinois Medicaid has set up protocols to remit payment of Medicaid overpayments and establish a one year conditional enrollment period for high-risk providers. Medicaid Overpayments – Public Act 097-0689 The Department of Healthcare and [...]Tags: Medical Billing, Provider Enrollment
IL – Illinois BCBS – PPO & Blue Choice Fee Schedule Update
3/21/2013 – BCBSIL will update its fee schedule effective with June 1, 2013 service dates. The fee schedules are updated in accordance with the annual update of the Schedule of Maximum Allowances (SMA) in relation to the CMS Resource Based Relative Value Scale (RBRVS) revisions and CMS fees for DME Supplies, Prosthetics, Orthotics and clinical laboratory [...]Tags: Medical Billing
Ohio Medicaid to Charge an Organization Enrollment Fee
3/21/2013 – Effective March 1, 2013, Ohio Medicaid began collecting a non-refundable application fee upon initial application to enroll as a Medicaid provider and also every 5 years at the point of revalidation. PLEASE NOTE: The fee applies to organizational providers only; it does not apply to individual providers and practitioners or practitioner groups. The [...]Tags: Medical Billing, Provider Enrollment
PA – BCNEPA – Mandatory Prior Authorization thru NaviNet
3/21/2013 – BCNEPA has enhanced the prior authorization submission and inquiry screen to ensure providers will have all the information they need when it becomes mandatory to request prior authorization through NaviNet only. Physicians began submitting prior authorizations in February 2013, but will be required to submit them as of April 1, 2013. At [...]Tags: Medical Billing, Prior Authorizattion
DE, NJ, PA – AmeriHealth Administrator’s Mailing Address Change
3/21/2013 Mailing Address Change AmeriHealth Administrators’ mailing address has changed. As they transition to the new address, some plan member ID cards may still show the old address. AmeriHealth asks that you update your records and correspondence to the new address listed below. AmeriHealth Administrators P.O. Box 21545 Eagan, MN 55121 Thus change [...]Tags: Medical Billing
CT – Community Health Network – Makes Change to EFT Process
3/21/2013 – On March 5, 2013, a change was made to the Electronic Funds Transfer (EFT) process. HP (Hewlett Packard Enterprise Services) will mail a letter to the provider confirming any changes made to their EFT information. The letter will contain both the previous and the new EFT data. Upon receipt of the [...]Tags: Medical Billing
MASS HEALTH – Revises 90-Day Waiver Claim Submission Procedures
March 21, 2013 – Effective April 1, 2013, 90-day waiver requests must be submitted electronically unless the provider has an approved electronic claim submission waiver. The electronic submission must be made via direct data entry (DDE) using the appropriate HIPAA delay reason code(s). Information describing the new procedures for the electronic submission of 90-day [...]Tags: Medical Billing
NH – HARVARD PILGRIM expands their Cost Estimator Tool to New Hampshire members.
3/21/2013 – Beginning on July 1, 2013, a new online health care cost estimator will be available to New Hampshire members enrolled in national plans offered jointly by Harvard Pilgrim Health Care and UnitedHealthcare. In NH, “myHealthcare Cost Estimator” will replace the “Treatment Cost Estimator” tool. In Massachusetts, “myHealthcare Cost Estimator” is currently available. [...]Tags: Healthcare Reform, Medical Billing
MA – Fallon Health Plan Offers Mobile e-card
3/21/2013 – Fallon Health Plan says it is the first insurer in Massachusetts to offer its members a mobile e-card. In January 2013, they began offering a free mobile ID card app for iPhone® and Droid® that members can show at their provider’s office and use to e-mail or fax an image of their [...]Tags: Healthcare Reform, Medical Billing
MA Blue Shield – New/Revised Policies for July 2013
3/21/2013 – Effective July 1, 2013, BCBSMA will implement the following new or revised payment policies. BCBSMA: will no longer reimburse for the professional component(modifier 26) of a radiology procedure when performed with an Evaluation and Management (E&M) service in an office setting by the same provider, on the same day. The professional component [...]Tags: Medical Billing
UnitedHealthcare Publishes Advance Notice and Pre-Certification Lists for 2013
3/21/2013 – In the March 2013 Network Bulletin , UnitedHealthcare published tables of services requiring advance notification, prior authorization or precertification by type of member plan and service. The articles below will give you the page number of these tables, which you may access by clicking on this Network Bulletin. Advance Notifixation List Updates [...]Tags: Advanced Imaging Services, Coding, Medical Billing, Prior Authorization
AETNA – Code Editing and Payment Policy Tool Enhancement
3/21/2013 – Aetna has enhanced its code editing, clinical, and payment policy look-up tool. The tool allows providers to determine how procedure codes billed alone or in combination with other procedure codes may be processed and to determine eligibility of an assistant surgery procedure. The tool also allows the provider to enter specific criteria [...]Tags: ASC Billing, Medical Billing
CMS – New Place of Service Policy Effective April 1, 2013
3/21/2013 – The new place of service (POS) policy for services paid under the Medicare Physician Fee Schedule is still scheduled to begin on April 1, 2013. Originally, the instructions were to begin on October 1, 2012. The instructions are basically the same as those released in October but with some clarifications. In [...]Final Rule Issued for Essential Health Benefits
3/6/2013 – In February, the Department of Health and Human Services (HHS) finalized a key ACA rule that defines the “essential health benefits” (EHBs) that must be provided by health insurers in 2014 to individuals and small-group businesses inside and outside health insurance exchanges, as well as in Medicaid. The benefits do not apply [...]Tags: ACA, Accountable Care Act, Healthcare Reform, Medical Billing
Final Interim Rule – Notice of Benefit and Payment Parameters
3/6/2013 – On March 1, the Department of Health and Human Services (HHS) released a final interim rule designed to stabilize premiums to prepare for the coming of state health insurance exchanges this fall. The ACA created three programs, risk adjustment, reinsurance, and risk corridors that will work with the premium tax credits, cost-sharing [...]Tags: ACA, Accountable Care Act, Affordable Care Act, CMS Updates, Health care Reform, Healthcare Reform, Medical Billing
CMS Announces New Comprehensive ESRD Care Model
3/6/2013 – CMS is offering a new payment and delivery model for end-stage renal disease, called the Comprehensive ESRD Care Initiative. You will find information for submitting a letter of intent and a an application for this program at the end of this article, along with registration information for CMS’ National Provider Call on March [...]Tags: ACA, Accountable Care Act, CMS Updates, Healthcare Reform, Medical Billing
CMS Issues Medical Loss Ratio Rules
3/6/2013 – As part of the ACA provisions, CMS has issued clarification on what Medicare plans must spend on care rather than marketing and overhead through the HHS Notice of Benefit and Payment Parameters for 2014. Starting January 1, 2014, Medicare Advantage and Part D Prescription drug plans will have to spend 85% of revenue on clinical services, prescription [...]Tags: ACA, Accountable Care Act, Affordable Care Act, Healthcare Reform, Medical Billing
Sequestration Impact on Physicians to start April 1
March 1, 2013 – As everyone knows, today the “sequestration” budget cuts go into effect. Even though leaders from both sides of the aisle will meet with President Obama today to try and reach a deal to avert the sequester, it seems unlikely this will be accomplished right away. The sequester could also be [...]Tags: Health care Reform, Medical Billing, Sequestration
RI – RHODE ISLAND BCBS – Transitional Care Management Policy
2/15/2013 – Effective January 1, 2013, two new CPT codes were created for the coverage of transitional care management services. RIBCBS has issued a new policy to address items not specifically addressed by CPT and those items where CMS and CPT may appear to differ. Otherwise all other CPT guidelines apply. Transitional care management [...]Tags: Coding, Healthcare Reform, Medical Billing
MA – TUFTS HEALTH PLAN – Update to Scar Revision Policy
2/15/2013 – Effective with service date of April 1, 2013, the prior authorization program for scar revision will be transitioned from the Tufts Health Plan Necessity Guidelines to Interqual® criteria. The Interqual® Smart Sheet™ must be completed and faxed to the Tufts Health Plan Precertification Department to obtain prior authorization for the following services, [...]Tags: Medical Billing, Surgery Billing, Surgery Coding
NY – Empire BCBS – New Guidelines for PA of Sleep testing and Therapy Services
2/14/2013 – The following information has been taken directly from the February edition of Empire’s newsletter, Network Update. This policy is effective March 1, 2013 Empire will introduce a new specialty benefit management program for sleep testing and therapy services performed on or after March 1, 2013. This new program will consider the medical [...]Tags: Coding, Medical Billing
RADIOLOGY & the EHR Incentive Specialty Hardship Exception
2/14/2013 – Recently CMS addressed the question concerning the specialty codes for those specialties granted the hardship exception from the EHR Incentive Program payment adjustments. Here is the FAQ: Question: What are the specific medical specialty codes associated with anesthesiology, radiology and pathology for the specialty-based determination for the granting of a hardship exemption [...]Tags: EHR, EHR Incentive Program, Healthcare Reform
Connecticut Medicaid – Updates
2/15/2013 Husky Program – Provider Re-Enrollment Applications Effective March 1, 2013, paper provider re-enrollment applications submitted to HP will no longer be accepted. All providers must submit their provider re-enrollment application via the online Wizard located on the http://www.ctdssmap.com website by clicking on Provider, then Provider Re-enrollment. Providers do not need to log on [...]Tags: Compliance, Documentation, Medical Billing
SGR on Congressional Drawing Board
2/14/2014 - Both Democrats and Republicans introduced bills the week of February 4th to eliminate the SGR formula in determining Medicare payment rates to providers. In addition, the CBO (Congressional Budget Office), announced their revision of the 10-year cost of fixing the SGR to $138 billion from $245 billion, down by more than 40%, based [...]Tags: Healthcare Reform, Medical Billing, SGR, SGR and Medicare Fee Schedule
CMS Seeking Provider Help to Align Quality Reporting
2/14/2013 – CMS is seeking help from providers to give them information on how clinical quality measure data that physicians are already reporting to medical boards, specialty societies, and other nonfederal programs, can be used to meet requirements of CMS’ incentive programs. The request is designed to reduce the burden for EPs and accelerate [...]Tags: EHR, EHR Incentive Program, Healthcare Reform, Maintenance of Certification Program, Medical Billing, PQRS Incentive Program
RI – BCBS Supports Health Information Exchange, CurrentCare
2/14/2013 – Per Rhode Island BCBS, one in every four Rhode Islanders is enrolled in the statewide Health Information Exchange, CurrentCare. CurrentCare is an integration of health information from non-affiliated health care organizations to the end-user through an Internet browser. It has been made possible through a joint effort by the Rhode Island Quality Institute [...]Tags: ACA, Accountable Care Act, Health care Reform, Health Exchanges, Health Insurance Exchanges, Medical Billing
NY – Empire BCBS Chooses “Castlight Health” for Employer Group Benefit
2/14/2013 – Empire BCBS will be offering a new employer group benefit option for expanded transparency through a third party vendor, Castlight Health. This new benefit option is in response to a growing number of national and local employers requesting expanded transparency tools that will help increase member engagement and improve the ability of [...]Tags: Compliance, Health care Reform, Medical Billing, Medical Billing Compliance
NJ – AmeriHealth – Migrating to Highmark Gateway
2/14/2013- Beginning this year, AmeriHealth Administrators will be migrating X12 transactions from the NaviNet® X12 Gateway to the Highmark Gateway. The intent is to streamline and improve processing activities. AmeriHealth expects to gain efficiencies and lower operating costs as well as add new capabilities that enhance the overall customer experience. In order to ensure a [...]Tags: Medical Billing
MA – TUFTS HEALTH PLAN – New Modifier Policy for Billing Bilateral Services and Suggestions for Prior Authorization Medical Documentation
2/14/2013 Commercial Claim Edits for Bilateral Modifiers The following claim edits will be in effect for Tufts Health Plan commercial claims adjudicated on or after April 1, 2013. Tufts will deny: Claim lines billed with modifier 50 and modifier LT or RT on the same line claim line. Procedure codes designated with a bilateral [...]NY – EMPIRE BCBS Updates Reimbursement Policies
2/14/2013 – On February 1, 2013, Anthem BCBS updated their Provider Services (AOPS) website with the following new and/or revised reimbursement policies. Frequency Editing – Professional For claims processed on or after February 18, 2013, Empire BCBS’ frequency Editing policy has been revised to add a frequency limit of four (4) units per [...]Tags: Coding, Medical Billing
CT – Anthem BCBS Updates Reimbursement Policies
2/14/2013 – On February 1, 2013, Anthem BCBS updated their Provider Services (AOPS) website with the following new and/or revised reimbursement policies. Frequency Editing – Professional For claims processed on or after February 18, 2013, Anthem BCBS’ frequency Editing policy has been revised to add a frequency limit of four (4) units per [...]Tags: Coding, Medical Billing
UnitedHealthcare – Medicare Solutions Reimbursement Policies
2/14/2013 – UnitedHealthcare publishes their policies that are related to CMS’ National Coverage Determinations (NCDs) and those related to Local Coverage Determinations (LCDs) and UnitedHealthcare Coverage Summaries. The content within the Medicare Solutions Reimbursement Policies includes: A summary of each policy, which may include coverage indications and/or limitations. Relevant CPT/HCPCS and ICP/PCS coding Particular [...]Tags: Coding, Medical Billing
UnitedHealthcare Will Launch iPhone®/iPad® App
2/14/2013 - On March 1, 2013, UnitedHealthcare will introduce their new interactive iPhone®/iPad® App to assist contracted providers in prescribing medications to their UnitedHealthcare patients. The program will allow providers to access UnitedHealthcare’s current base Prescription Drug Lists, members’ personal health records and drug reference information. For more information see their Frequently Asked Questions.Tags: Healthcare Reform, Medical Billing
CIGNA – New Website and Features
Tags: Coding, Medical Billing
AHS Resource Guides
AHS is pleased to offer you our resource guides for the major CMS Incentive Programs. You only need to go to one guide to get a good understanding of each of the programs. Each guide also includes all of the CMS website links for additional information. We hope these guides are useful to you. [...]Tags: CMS Updates, EHR, EHR Incentive Program, eRx Incentive Program, PQRS Incentive Program
CMS Finally Issues Sunshine Rule
2/4/2013 – CMS has finally issued the long-awaited Physician Payments Sunshine Act which will produce a database that will list payments made to physicians by pharmaceutical and device manufacturers. The focus of the ruling is to increase transparency and reduce the potential for conflicts of interest by gathering data about financial relationships between healthcare providers and manufacturers [...]Tags: Accountable Care Act, CMS Updates, Healthcare Reform
CMS Announces More Than 500 Provider Organizations Join Bundled Payment Initiative
2/4/2013 – On Thursday, January 31, 2013, CMS announced that more than 500 Participants joined the Bundled Payments for Care Improvement Initiative, a payment model program created by the ACA (Affordable Care Act) to test whether bundled payments for services in a single episode of care can improve quality and lower costs by reducing readmissions, duplicative care, [...]Tags: ACA, Accountable Care Act, CMS Updates, Healthcare Reform
Update on Medicare & Medicaid Overpayments & RAC Audit Collections
January 31, 2013 – There is now a longer time frame for Medicare and Medicaid to request and collect overpayments made to providers. A provision in the American Tax Relief Act of 2012 (ATRA), passed in early January to avoid the fiscal cliff, replaced the time frame of three (3) calendar years with five [...]Tags: CMS Updates, Fraud and Abuse, Healthcare Reform, Medical Billing Compliance
Organizations Request Evaluation of EHR Incentive Program Before Moving on to Stage 3
January 31, 2013 – In November, ONC (Office of the National Coordinator for Health Information Technology) published recommendations for meaningful use Stage 3 requirements to be effective in 2016. ONC sets the initial standards, implements specifications, and creates the certification criteria for EHR technology. Their Stage 3 recommendations reiterate Stage 2 goals but with [...]Tags: EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use
OIG Finds Problems with CMS’ Oversight of EHR Incentive Program
1/31/2013 – In a report released in November 2012, the Office of Inspector General (OIG) found that CMS faces obstacles in their oversight of the Medicare EHR Incentive Program that leaves the program vulnerable to paying incentives to eligible professionals (EPs) and hospitals (referred to in this article as “providers”) that do not fully [...]Tags: CMS Updates, EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use
MA – HARVARD PILGRIM – 2013 Policy for Stent Placement
01/23/2013 – As of January 1, 2013, HPHC will not reimburse the 2013 C codes which replaced the following 2012 G codes: G0290 – Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel, and G0291 – ; each additional vessel In general, HPHC does [...]Tags: Coding, Medical Billing
IN, OH – ANTHEM BCBS – Claim Edits for Cardiac Services with Sleep Studies
01/22/2013 – Anthem BCBS has issued their customized claim edits which apply to the following products, effective January 6, 2013. Blue Access®, Blue Access Choice, Blue Preferred®, Blue Preferred Primary, Blue Preferred Primary Plus, Blue Preferred Plus, Blue Priority, Blue Priority Plus, Blue Traditional®, Hospital Surgical (PPO) Blue Traditional®. Anthem bundles the following [...]Tags: Coding, Medical Billing
MA – HPHC Contracts with NPs and PAs as PCPs
01/23/2013 – HPHC recently announced their credentialing process for Nurse Practitioners (NPs) and Physician Assistants (PAs) who want to contract with them as PCPs. HPHC previously contracted with NPs who wish to serve as PCPs in the areas of family practice, gerontology, adult and pediatric medicine. New Massachusetts legislation now allows PAs to apply [...]Tags: Medical Billing
Medicaid Primary Care Rate Increase
1/23/2013 – For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act (ACA) requires Medicaid agencies to reimburse Medicare payment rates for the following primary care services provided by the listed primary care physicians. Eligible Services E & M Codes 99201-99499 CPT vaccine administration codes 90460, 90461, 90471, 90472, [...]Tags: ACA, Affordable Care Act, Healthcare Reform, Medical Billing
MA – HARVARD PILGRIM (HPHC) – Updates Guidelines for PET Scans
01/22/2013 – Effective for service date beginning April 1, 2013, HPHC will update the list of covered clinical indications for PET Scans. HPHC only reimburses contracted providers for PET scans performed on FDA-approved equipment at contracted facilities and PET imaging centers. HPHC contracts with National Imaging Associates (NIA) to manage their PET Scan policy. [...]Tags: Medical Billing, radiology bililng, Radiology Coding
IN, OH – ANTHEM BCBS – Updates Certain Imaging Guidelines
01/22/2013 – Effective April 15, 2013, AIM (American Imaging Management), Anthem’s advanced diagnostic imaging manager, will revise guidelines for the following diagnostic tests in order to enhance the appropriateness of care: CT of Cervical, Thoracic and Lumbar spine MRI of Cervical, Thoracic and Lumbar spine CT of Upper Extremity MRI of Upper Extremity The guidelines [...]Tags: Medical Billing, Radiology Billing, Radiology Coding
IN, OH – Anthem BCBS – Claim Edits for Fluoroscopy Guidance
01/22/2013 – Anthem BCBS has issued their customized claim edits which apply to the following products: Blue Access®, Blue Access Choice, Blue Preferred®, Blue Preferred Primary, Blue Preferred Primary Plus, Blue Preferred Plus, Blue Priority, Blue Priotiry Plus, Blue Traditional®, Hospital Surgical (PPO) Blue Traditional®. Anthem bundles the Fluoroscopic guidance codes: 77001 (central venous [...]Tags: Medical Billing, Radiology Billing, Radiology Coding
IL – BCBSIL Offers Diagnostic Incentive Program for City of Chicago Members
01/22/2013 – Effective January 1, 2013, BCBSIL offered the City of Chicago a diagnostic testing incentive program that will pay 100% of members’ services with no deductible, coinsurance or copay. In order to reap these benefits, ILBCBS members must use a free-standing in-network laboratory or free-standing imaging center for tests ordered by their physician. [...]Tags: Medical Billing, Radiology Billing
UNITED HEALTHCARE – Radiology 2013 Notification & Prior Authorization Program
1/22/2013 – UnitedHealthcare updated their procedure code list for the Radiology Notification and Prior Authorization Programs based on the 2013 CPT code changes. The following thyroid codes will be added to the listing. 78012 – Thyroid Update, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) 78013 – Thyroid imaging (including [...]Tags: Advanced Diagnostic Imaging Billing, Advanced Imaging Services, Medical Billing, Radiology Billing, Radiology Coding
CMS Offers Tipsheet to Specialists Trying to Meet EHR Meaningful Use
1/22/2013 – After numerous questions regarding how Specialists can qualify for or avoid the penalties of the EHR Incentive Program, CMS has published a Tipsheet to provide information on how Specialists may meet the meaningful use criteria (MU). The tipsheet covers reporting measures, reporting measure exclusions, how to use other providers’ data, determining office [...]Tags: EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use
Medicare EPs must Attest by February 28, 2013 to Get Paid for 2012 EHR Incentive Program Participation
1/17/2013 – Eligible professionals (EPs) who participated in the Medicare EHR Incentive Program in 2012 must complete attestation by February 28, 2012 in order to receive an incentive payment. EPs must also have completed their reporting requirements by December 31, 2012. CMS encourages Medicare EPs to register and attest as soon as possible in case [...]Tags: EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use, Medical Billing
HHS Implements Changes to HIPAA Privacy & Security Rule
1/22/2013 – The U.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR) has finalized changes to the HIPAA Privacy and Security Rules, through the new final rule issued on January 17, 2013. Called the “omnibus” privacy and security rule because of its broad reach, the rule “greatly enhances a patient’s privacy [...]Tags: Compliance, Healthcare Reform, HIPAA, Medical Billing, Medical Billing Compliance
NY MEDICAID – OMNI 3750 POS Card Swipe to be Terminated
1/17/2013 – Effective March 31, 2013, the OMNI 3750 Point of Service device will be discontinued. Providers who currently use this system to verify Medicaid eligibility or request Dispensing Validation System (DVS) prior approval must switch to one of the following real-time methods prior to the March 31, 2013 date. Electronic Provider Assisted Claim [...]Tags: Medical Billing
MA – BMC & NHP Will Require NDC Code on Claims
January 17, 2013 – Both BMC HealthNet and NHP (Neighborhood Health Plan) have been instructed by Mass Health that effective with service date February 1, 2013, providers must report the 11-digit National Drug Code Number (NDC) on all qualifying claim forms when injectable physician-administered drugs are administered in the office or outpatient setting. BMC [...]Tags: Medical Billng
MA – BCBSMA Changes Filing Limit for PPO Secondary Claims
1/17/ 2013 – Effective February 1, 2013, BCBSMA is changing their filing limit for PPO secondary claims from one year from the primary carrier’s date of denial to 90 days from the primary carrier’s date of denial. This change is consistent with their filing limit for HMO and PPO initial claims submissions. HMO, PPO [...]Tags: Medical Billing
Illinois Providers Should Expect Drastic Slowdown to Obtain and Renew Medical Licenses
1/17/2013 – Last week the Department of Finance and Professional Regulation’s Medical Unit (Department) sent a letter announcing a layoff that would result in a reduction of its staff from 26 to 8. It is estimated that this layoff could delay the processing of medical licenses between 12 – 18 months and will place [...]Tags: Medical Billing, Provider Enrollment
CMS Announces 106 New Medicare ACO Organizations
1/17/2013 – On January 10, 2013, CMS announced the addition of 106 new Medicare Accountable Care Organizations (ACOs), giving access to coordinated care to as many as 4 million Medicare beneficiaries. Since passage of the Affordable Care Act, more than 250 Accountable Care Organizations have been established. The new group includes 15 Advance Payment Model [...]Follow-up to the 2013 MPFS, SGR, and Sequestration
1/9/2013 – Now that the American Taxpayer Relief Act (ATRA) of 2012 has averted the 26.5% SGR Medicare payment reduction until 2014, here are a few other provisions or results of that legislation to take place in the next few months. 2013 Medicare Physician Fee Schedule (MPFS) – By delaying the 26.5% SGR cut, the 2013 [...]Tags: 2013 Medicare Physician Fee Schedule, ACA, Medical Billing, SGR, SGR and Medicare Fee Schedule
Last Chance to Avoid the eRx 2014 Payment Penalty
1/9/2013 Eligible professionals (EPs) who did not successfully report and qualify for the 2012 eRx incentive program, reporting period of January 1, 2012 – December 31, 2012, will have another opportunity to avoid the 2014 payment adjustment (penalty) of 2% on their Medicare Part B payments. (Providers who are exempt from eRx reporting are [...]Tags: eRx Hardship Exemptions, eRx Incentive Program, Medical Billing
The Importance of Participating in the 2013 PQRS Program
1/9/2013 – We want to remind everyone that those not participating in the PQRS Incentive Program this year will be penalized in 2015 by a reduction of 1.5% of their Medicare payments in 2015. CMS is using year 2013 as a benchmark for future penalties, not only for the PQRS program, but also for [...]Tags: 2013 Medicare Physician Fee Schedule, CMS Updates, PQRS Incentive Program
2013 Enrollment Application Fee for Institutional Providers
1/9/2013 – The CMS Enrollment Application fee for institutional providers for 2013 is $532.00, up from $525.00 in 2012. CMS has defined “institutional provider” to mean any provider or supplier that submits a paper Medicare enrollment application using CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S forms or associated Internet-based PECOS enrollment application The application fee is [...]Tags: Medical Billing, Provider Enrollment
Enforcement of Administrative Simplification Rules Delayed 90 Days
1/9/2013 – The new rules that will enforce health insurance plans to support the same standards for insurance eligibility verification and claim status electronic transactions will still be effective January 1, 2013, but CMS has delayed the enforcement date until March 31, 2013. This delay is intended to reduce the potential disruption to the [...]Tags: ACA, Accountable Care Act, HIPAA, Medical Billing, Medical Billing Compliance
SGR 26.5% Cut Averted for 2013 and 2% Sequestration Cut Delayed until March
1/2/2013 - Late last night, the House of Representatives voted to pass the American Taxpayer Relief Act, also known as the “fiscal cliff” bill, which was passed earlier by the Senate. The bill delays the Medicare SGR cut of 26.5% for another year and pushes back the 2% sequestration cut for two months. The bill [...]Tags: SGR, SGR and Medicare Fee Schedule
Insurers Introduce New Price Transparency Tools
12/28/2012 - In 2013, insurance premium costs are expected to rise and more patients will have insurance policies with higher deductibles and co-insurance. Over the last year or so, in order for insurers to keep their costs down and assist their members in lowering their out-of-pocket responsibility, insurance carriers have been offering patients and employers [...]Tags: Medical Billing, Price Transparency
NY – EMPIRE BCBS – New Plans in Development for NY State Insurance Exchange
12/28/2012 - Empire is developing new individual and small group health benefit plans that will be offered on the NY State Insurance Exchange starting January 1, 2014. Empire expects to offer these benefit plans to individual and small groups that satisfy certain eligibility criteria. Empire is building a participating provider network of all provider types, [...]Tags: Medical Billing
Aetna’s Medicare Advantage Cost Share Changes in 2013
12/28/2012 – Effective January 1, 2013, Aetna Medicare Advantage (MA) HMO plan members’ cost sharing responsibilities for certain benefits will change. Instead of a copayment, Aetna MA HMO plan members will be required to pay coinsurance for the following benefits: • Part B drugs • Durable medical equipment (DME) • Complex radiology (MRI, MRA, [...]Tags: Medical Billing
MA – BMC HealthNet Plan – NDC Must Be Reported in 2013
December 28, 2012 – Mass Health has now notified BMC that effective with service date January 15, 2013, providers must report the 11 digit National Drug Code Number (NDC) on all qualifying claims forms when injectable physician-administered drugs are administered in the office or an outpatient setting. This requirement excludes applicable vaccines/immunizations and [...]MA – BCBSMA – New XXS ID Prefix
12/28/2012 – Approximately 40,000 new BCBSMA members have received new prefix ID numbers beginning with XXS. It is important for providers to check member eligibility prior to rendering services and submit the most up-to-date member ID, including the new alpha prefix. The new ID numbers must be submitted for payment. Outdated alpha-prefixes will be [...]Tags: Medical Billing
MASSHEALTH – Group Practice Providers Paid Based on Rendering Physician ID
December 28, 2012 - MassHealth has implemented a processing change for Part B crossover claims billed by group practice providers. As of 12/16/12, all Part B crossover claims submitted by group practice providers will be priced based on the rendering provider ID submitted in the claim detail. Previously, MassHealth priced these claims based on the [...]Tags: Medical Billing
ILLINOIS BCBS – Blue Worldwide Expat Product Terminated
12/28/2012 – Effective November 30, 2012, BCBS health insurance coverage for members with Blue Worldwide Expat was terminated. These member’s ID cards started with alpha prefix EXF. This Worldwide coverage will be replaced by Worldwide Insurance Services (doing business as GeoBlue). As of December 1, 2012, three offerings for international travelers and expatriates will [...]Tags: Medical Billing
MA – HARVARD PILGRIM (HPHC) – Payment Policies for Unreliable and Obsolete Tests and Procedures
12/28/2012 – HPHC does not reimburse for tests and procedures that are considered experimental and investigational or for tests and procedures that CMS has found to be obsolete or unreliable. Effective January 1, 2013, HPHC will add these CPT procedure codes into its Obsolete and Unreliable Tests and Procedures Payment Policy. 43754 – Gastric [...]Tags: Medical Billing
MA – BMC HealthNet – Payment Policy for Multiple Endoscopic Procedures
12/28/2012 – The following multiple endoscopic procedures policy will take effect on January 1, 2013. When multiple endoscopies with the same base code are reported, the highest valued endoscopy is paid 100% plus the difference between the allowed amount for each subsequent endoscopy and the based code allowed amount. When multiple endoscopies with the [...]Tags: Medical Billing
ILLINOIS BCBS – Preventive Colonoscopy Billing
12/28/2012 – BCBSIL has automated processing for preventive colonoscopy claims with modifiers PT and 33. Health care providers should already be using modifier 33, which became effective January 1, 2011. Modifier 33 may be used when the primary purpose of the service is the delivery of an evidence-based service in accordance with a legislative [...]Tags: Medical Billing
MA – Harvard Pilgrim (HPHC) – 2013 Injection Policy Changes
12/28/2012 – Effective January 1, 2013, HPHC will reimburse the following procedures only when medically necessary and appropriate and when billed with the covered CPT and ICD codes listed in their payment policy for injections into the tendon sheath, ligament cyst, carpal tunnel, and tarsal tunnel. 20527 – Injection, enzyme (e.g., collagenase), palmar fascial cord [...]Tags: Medical Billing, Surgery Billing, Surgery Coding
Medicare Premiums & Deductibles for 2013
12/5/2012 – CMS has released the Medicare premiums and deductibles for Medicare beneficiaries in 2013. Medicare Part B – Physician & Non-Physician Services Coverage CMS will increase the Medicare Part B premium $5 a month to $104.90 a month. People with Medicare who report 2011 income above $85,000 a year ($170,000 filing jointly) are [...]Tags: CMS Updates, Medical Billing
More ACA Rules to be Released Soon
12/5/2012 – Soon the Obama administration will release more new rulings clarifying how to implement the provisions in the Affordable Care Act (ACA). Here are some of those expected rulings. Medical Device Excise Tax The Internal Revenue Service proposed a rule at the beginning of 2012 on how to apply the 2.3 percent [...]Tags: ACA, Affordable Care Act, Bundled Payments, Healthcare Reform
Proposed ACA Rules Released
12/5/2012 – On November 20, 2012, the Department of Health & Human Services and the Department of Labor jointly released three proposed rules outlining how provisions under the ACA would work concerning: Pre-existing or Chronic Conditions Establish Essential Health Benefits Establish/Expand Wellness Programs These proposed rules are still open for comment until December 26, [...]Tags: ACA, Affordable Care Act, Healthcare Reform, Medical Billing
Administrative Simplification Begins January 1, 2013
12/5/2012 – New rules will go into effect on January 1, 2013, that will enforce health insurance plans to support the same standards for insurance eligibility verification and claim status electronic transactions. This implementation should be cost effective for providers as it will institute greater uniformity of information and transmission formats so that practices can [...]Tags: ACA, Accountable Care Act, Administrative Simplification, Healthcare Reform, Medical Billing
Medicare Provider Compliance Newsletter
12/5/2012 – CMS has recently issued the Fall Edition of their Quarterly Provider Compliance Newsletter. CMS issues the “Medicare Quarterly Provider Compliance Newsletter,” a Medicare Learning Network® (MLN) educational product, to help providers understand the major findings identified by Medicare Administrative Contractors (MACs), Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error [...]Tags: Audits, Compliance, Fraud and Abuse, Medical Billing, Medical Billing Compliance, RAC Audits
CMS Releases Updates to Medical Records Requirements
12/5/2012 – CMS has released updates, effective December 10, 2012, to its Medicare Program Integrity Manual section on medical reviews performed by its contractors including the following contractors: Recovery Audit Contractors (RAC) Medicare Administrative Contractors (MACs) Comprehensive Error Rate Testing Contracters (CERT) Zone Program Integrity Auditors (ZONE) CMS issued Change Request 8033 which defines [...]Tags: CMS Updates, Compliance, Documentation, Medical Billing, Medical Billing Compliance
Physician Reimbursement for 2013
12/5/2012 - It is the beginning of December and, as we have experienced over the last few years, we still do not know what next year’s Medicare reimbursement will be for physicians and non-physician practitioners. Most in the medical and political community feel Congress will again postpone an SGR reduction and keep 2013’s fees on [...]Tags: GPCIs, Medical Billing, Relative Value Units, Sequestration, SGR, SGR and Medicare Fee Schedule
MA – TUFTS – Surgical Procedures Added to Prior Auth List in 2013
11/21/2012 – Effective January 1, 2012, the following surgical procedures will be added to Tufts Health Plan’s prior authorization programs for their commercial products. Spinal Procedures: 22845 – Anterior instrumentation; 2 to 3 vertebral segments (add-on code) 63050 – Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertical segments; 63051 ; [...]Tags: Medical Billing, Prior Authorization, Surgical Billing
MA – HPHC – Policy Change for Multiple Procedures on the Same Day
11/20/2012 – Effective January 17, 2013, Harvard Pilgrim Health Plan (HPHC), will change their Radiology Payment Policy for performing multiple procedures on the same day by consolidating the existing radiology contiguous relationship code sets into a single family of codes. Currently HPHC applies their MPPR (multiple procedure payment reduction) policy to the professional and technical [...]Tags: Medical Billing, MPPR, Radiology Billing, Radiology Coding
AETNA Offers Radiology Smart Choice Program in 14 states
11/20/2012 – Effective November 1, 2012, Aetna has offered their Smart Choice Program in 14 states. The Smart Choice Program provides cost transparency to members who need radiology services. MedSolutions, a medical management services company, will contact Aetna members to discuss radiology options and help them schedule radiology services. These are the states currently participating [...]Tags: Medical Billing, Radiology Billing
COVENTRY Contracts with ICORE to Manage Prior Auths for Injectable Drugs
11/20/2012 – Effective December 1, 2012, Coventry HealthAmerica will engage ICORE Healthcare, LLC, a subsidiary of Magellan Health Services, to manage the prior authorization process for certain medical injectable drugs. This contract will only be valid for Coventry HealthAmerica’s, HMO, POS, PPO and Medicare Advantage Plan, HealthAmerica Advantra. Prior authorization will be required for drugs [...]MA – TUFTS – E/M Service to be Bundled in Stress Test for Medicare Plan
11/20/2012 – Effective January 1, 2013, Tufts Health Plan Medicare Preferred will not separately reimburse for an E/M service when billed on the same day as a cardiac stress test, as the E/M service is included in the stress test. Should separately identifiable E/M services be rendered on the same day as a stress test, [...]Tags: bundled services, Medical Billing
MA – FALLON – Enhances SMS Contract for Sleep Management Services
11/20/2012 – Effective January 1, 2013, Fallon has contracted with SMS (Sleep Management Solutions) to assume sole responsibility for all components of the sleep program, including prior authorization, network management and claims payment for sleep services. (see below for policy exceptions) SMS currently contracts with CareCore National to provide prior authorization services for the Fallon [...]Tags: Medical Billing
Aetna Changes Service Type for Many Procedures
11/20/2012 – Aetna has announced that as of January 1, 2013, the following procedures will no longer be considered diagnostic in nature, but as surgical services. As a result of this change, claims for these procedures may begin to be reimbursed at the surgical rate, instead of the diagnostic rate under the provider’s contract. If [...]Tags: Coding, Medical Billing, Reimbursement rates
UNITED HEALTHCARE – Anesthesia Policy Revision
11/20/2012 – United Healthcare will revise its Anesthesia policy to remove the edits related to the submission of transesophageal echocardiography (TEE) codes 93312 – 93318 reported in conjunction with anesthesia management services (00100-01999 excluding 10996 and 01953) Per CMS’ National Correct Coding Initiative (NCCI) which will go into effect in 2013, separate reimbursement of TEE [...]Tags: Anesthesia Billing, Anesthesia Coding, Medical Billing
Coventry HealthAmerica Revises Prior Authorization Requirements
11/19/2012 – Effective January 1, 2012, there will be several changes to Coventry’s HealthAmerica Prior Authorization requirements. Services eliminated from the prior authorization list Certain procedures in the following categories will no longer require prior authorization: Contraceptive (commercial plans), cosmetic services/treatment, diagnostic testing/procedures, home health care, infusion therapy, surgical/medical procedures involving the following systems: nervous [...]NY Medicaid Covers Medical Language Interpreter Services
11/19/2012 – Effective October 1, 2012, NY Medicaid began to reimburse certain providers for interpretive services for Medicaid members with limited English proficiency and communication services for members who are hard of hearing. Effective on December, 1, 2012, these services will also be reimbursed to providers for Medicaid Managed Care and Family Health Plus members. [...]Tags: Coding, Medical Billing
United Healthcare Updates
11/19/2012 – UnitedHealthcare (UHC) will update several billing policies in the first quarter of 2013. Some were changed in order to align with CMS’ policies and others for clarification purposes. The following are brief summaries of these policy changes. More information can be found in UHC’s November Newsletter, on pages 12 – 14. Professional/Technical Component – [...]Tags: Coding, Medical Billing, Radiology Billing, Radiology Coding
MA – TUFTS HEALTH PLAN – Change to PC/TC Modifier Policy
11/19/2012 – Tufts will institute new claim edits effective for their commercial claims adjudicated on or after January 1, 2013 for the following: Tufts will no longer add or remove modifiers 26 (professional component) or TC (technical component) to procedure codes requiring the presence or absence of those modifiers in order to apply existing PC [...]Tags: Medical Billing, Modifiers
NJ – HORIZON BCBS – Hurricane Sandy Delays Member ID Cards
11/19/2012 – Hurricane Sandy damaged Horizon Blue Shield’s Harrison, NJ’s printing facility, resulting in a delay in issuing new Horizon BCBSNJ ID cards to some members. Horizon has mailed enrollment confirmation letters to these members for them to use until their ID card has arrived. The letters include the Subscriber’s name, Horizon ID number, Contract [...]Tags: Medical Billing
UnitedHealthcare – “New Patient Visit” Policy Revised
11/19/2012 – Recently, UnitedHealthcare updated their “new patient visit” policy by changing the language to align their definition of these services with CMS. The policy now defines a new patient as “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group [...]Tags: E & M billing, Medical Billing
CMS Raises Medicaid Rates for Primary Care Services
11/14/2012 – On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to implement increased payments to primary care physicians for specified Medicaid services, as authorized by the Affordable Care Act (ACA). Under the ACA provision, certain physicians who provide eligible primary care services will be paid the Medicare rates (as [...]Apply for eRx Hardship Exemption to Avoid 2013 Payment Adjustment
11/14/2012 – On November 1, 2012, CMS re-opened their Communication Support Page to allow individual eligible professionals (EPs) and CMS-selected group practices to apply for hardship exemptions for the 2013 eRx payment adjustment. The following eRx exemption categories are those which can be applied for through the Communication Support Page and must be submitted before [...]Tags: CMS Updates, eRx Hardship Exemptions, eRx Incentive Program, Medical Billing
CMS Finalizes 2 eRx Exemptions Tied to EHR Incentive Program Participation
11/14/2012 – On November 1, 2012, in the 2013 Medicare Physician Fee Schedule Final Rule, CMS finalized the two proposed electronic prescribing (eRx) significant hardship exemptions pertaining to the EHR Medicare and Medicaid Incentive Program. The proposed exemptions were meant to address the overlapping eRx requirements of the eRx Incentive Program and the Medicare and Medicaid [...]Tags: 2013 Medicare Physician Fee Schedule, EHR Incentive Program, eRx Incentive Program, Medical Billing
MGMA Opposes Legislation to Limit Ancillary Services for Group Practices
11/14/2012 – The following article was published in the MGMA’s Washington Connexion on November 1, 2012. MGMA opposes legislation to limit the provision of ancillary services within group practices On Monday MGMA, the American Medical Association, American College of Physicians, and American College of Surgeons joined over twenty medical associations in voicing opposition to proposed [...]Tags: Advanced Diagnostic Imaging Billing, Advanced Imaging Services, Healthcare Reform, Medical Billing, Pathology Billing, Radiology Billing, Stark Law
CMS Releases the 2014 Meaningful Use Clinical Quality Measures (CQMs)
November 14, 2012 - Although the EHR Incentive Program Stage 2 Final Rule was released on August 23, 2012, the final clinical quality measures (CQMs) to be reported for the 2014 program were only recently published by CMS. Beginning January 2014, providers will report on 9 of these 64 CQMS regardless of whether they are in [...]Tags: CMS Updates, EHR, EHR Incentive Program, Healthcare Reform, Meaningful Use, Medical Billing
2013 Medicare Physician Fee Schedule – Specialists
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to specialists. SGR and the 2013 Fee Adjustments If [...]Tags: 2013 Medicare Physician Fee Schedule, Coding, Medical Billing, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Radiology & Radiation Oncology
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to radiology and radiation oncology SGR and the 2013 [...]Tags: 2013 Medicare Physician Fee Schedule, Medical Billing, Radiology Billing, Radiology Coding, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Pathology
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to pathology. SGR and the 2013 Fee Adjustments If [...]Tags: 2013 Medicare Physician Fee Schedule, Medical Billing, Pathology Billing, Pathology Coding, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Anesthesia
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to anesthesia services SGR and the 2013 Fee Adjustments [...]Tags: 2013 Medicare Physician Fee Schedule, Anesthesia Billing, Anesthesia Coding, Medical Billing, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Medicine
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to medicine and primary care physicians. SGR and the [...]Tags: 2013 CPT Codes, 2013 Medicare Physician Fee Schedule, Medical Billing, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Non-Physician Practitioner
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to non-physician practitioners. SGR and the 2013 Fee Adjustments If [...]Tags: 2013 Medicare Physician Fee Schedule, Coding, Medical Billing, Non-Physician Practitioner Billing, SGR, SGR and Medicare Fee Schedule
2013 Medicare Physician Fee Schedule – Surgery
11/14/2012- On November 1, 2012, CMS released the 2013 Medicare Physician Fee Schedule (MPFS) final rule with comment, which modified or finalized the proposed fee schedule rule released in July 2012. Here are some of the general provisions of the 2013 MPFS, followed by provisions specific to surgeons. SGR and the 2013 Fee Adjustments If Congress [...]Tags: 2013 CPT Codes, 2013 Medicare Physician Fee Schedule, ASC Billing, Medical Billing, SGR and Medicare Fee Schedule, Surgery Coding, Surgical Billing
AETNA Updates In-Office Surgical Pathology Policy
10/23/2012 – Last spring, Aetna issued a policy that required their participating providers who perform in-office surgical pathology testing to be accredited by CLIA and at least one other accrediting entity.(Dermatologists are exempt from this requirement) In response to feedback Aetna received from providers, Aetna is updating their in-office surgical pathology testing policy by extending the [...]Tags: Medical Billing, Pathology Billing
AETNA Updates In-Office Surgical Pathology Services
10/23/2012 – Last spring, Aetna issued a policy that required their participating providers who perform in-office surgical pathology testing to be accredited by CLIA and at least one other accrediting entity.(Dermatologists are exempt from this requirement) In response to feedback Aetna received from providers, Aetna is updating their in-office surgical pathology testing policy by extending the [...]Tags: Coding, Medical Billing, Pathology Billing, Pathology Coding
NY – MEDICAID – National Drug Codes Must Be Reported on Claims
10/23/2012 – Effective September 20, 2012, reporting of the National Drug Code (NDC) is now required for all Physician Administered Drugs on claims for Medicaid Managed Care and Family Health Plus recipients. All providers should report the name of the drug and, if possible the NDC code, on their charge tickets to AHS so we [...]Tags: Coding, Medical Billing
AMA and Others Continue to Offer Alternatives to Replace the SGR
October 22, 2012 – The AMA, MGMA, and others continue to submit alternatives to the SGR payment formula to Congress. On October 15, these organizations, along with 100 state and specialty medical societies, issued a set of principles outlining “the foundation of a new system that supports physicians in improving the delivery of care with [...]Tags: Healthcare Reform, SGR and Medicare Fee Schedule
CMS Awards new MAC Contracts
October 22, 2012 – Three new MAC contract awards that affect several of our clients were granted in September. As part of the on-going process of competitively bidding and awarding the Medicare Administrative Contractor contracts, CMS announced earlier this year that it was accepting bids on new MAC contracts for various regions of the country. Most [...]Tags: CMS Updates, Medical Billing
CMS Releases 2011 Medicare e-prescribing Incentive Payments Feedback Reports
October 22, 2012 – Feedback reports for the Medicare e-prescribing 2011 incentive payments are now available. The reports can be downloaded via the QualityNet website. Individual eligible professionals (EPs) can request their National Provider Identifier (NPI) level reports through the Communication Support Page. CMS expects to email the report to the address provided in the [...]Tags: CMS Updates, eRx Incentive Program, Healthcare Reform
RI MEDICAID – Upcoming Audits & Changes in Prior Authorizations
October 22, 2012 Payment Error Rate Review (PERM) Effective January 1, 2013, the State of Rhode Island will take part in the PERM review by CMS. PERM requires the heads of Federal agencies to annually review programs they oversee that are susceptible to significant erroneous payments. They are responsible to estimate the amount of improper [...]Tags: Audits, Compliance, Fraud and Abuse, Medical Billing, Payment Error Rate Review(PERM)
NY – Empire BlueShield Introduces a New Provider Network
10/22/2012 – Empire BCBS will introduce a new provider network in the first quarter of 2013 called “Blue Priority Network.” This will be a limited provider network made up of a subset of Empire’s participating providers. Only providers not selected for participation in the new network will receive notification of their exclusion. Provides who do [...]Tags: Medical Billing
NY – Empire BCBS – Site of Service & Modifier Reduction
October 22, 2012 Site of Service Reduction Effective March 1, 2013, Empire BCBS will update their listing of Site of Service reductions to reflect the 2012 CMS Region 2 percentages and beginning in August 2013, will align their reductions to the 2013 CMS percentages. Starting in 2014, updates will be annual on March 1 or [...]Tags: Billing with Modifiers, Medical Billing, Site of Service Reduction
NY – EmblemHealth Announces New Lab Ordering Tool – Care360®
EmblemHealth has announced a new tool to order lab tests and obtain results from Quest Diagnostics, their preferred diagnostic testing laboratory. The tool is called Care360® and the service is free of charge. In order to use this new tool, providers must enroll at the Care360 website. Some of the benefits of using this tool [...]Tags: Medical Billing
NJ – AmeriHealth – New Medicare Advantage HMO Plan for 2013
October 22, 2012 – Beginning January 1, 2013, AmeriHealth will introduce AmeriHealth 65 Preferred HMO, an enhanced Medicare Advantage HMO plan. Members will continue to receive the same benefits as Original Medicare as well as access to the Silver Sneakers® Fitness Program; preventive care; health resources and wellness programs; and support for managing chronic conditions, such [...]Tags: Medical Billing, Medicare Advantage Plans
MA – BCBS MA – Prolonged Services
October 22, 2012 – Effective January 1, 2013, BCBSMA will not routinely reimburse for prolonged physician services in conjunction with E/M services. These services may be reimbursed only after requesting individual consideration and based on the submission of supporting documentation. More information will be provided as we get closer to the new year.Tags: Medical Billing, Prolonged Services
MA BCBS Audits and Expands Modifiers
October 22, 2012 Medical Record Audits Will Focus on the Use of Modifiers Over the next several months, BCBSMA will be conducting audits to verify the appropriate use of modifiers 25 and 59—two modifiers that are frequently billed incorrectly. Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the [...]Tags: Billing with Modifiers, Medical Billing
IN & OH – Anthem BCBS – Sign up for “My Anthem” Now
10/22/2012 – The transition of Anthem member eligibility, benefits, claim status and secure messaging information from MyAnthem for Providers to Availity® is almost here. Providers who have not registered for Availity should do so as soon as possible because My Anthem for Providers will no longer provide this information to portal users as of November 2, [...]Tags: Medical Billing
IL – Illinois Medicaid Releases 2013 Physician Fee Schedule
10/22/2012 - Illinois Medicaid has released their 2013 Practitioner Fee Schedule which can be viewed here.Tags: Medical Billing, Physician Fee Schedules
FLORIDA Medicaid to Take-Back Medicare Part B Crossover Incorrect Payments
10/22/2012 – Florida’s Agency for Health Care Administration (AHCA) completed a review this past summer of Medicaid claims reimbursed from 2008 – 2011 for Medicare Part B crossover claims in order to identify incorrectly paid claims. Adjustments for incorrectly paid claims began on October 12, 2012 and are identifiable by a “52” region code on [...]Tags: Medicaid takebacks, Medical Billing
HUMANA – 2013 Preauthorization and Notification Updates
October 22, 2012 – On January 28, 2013, Humana will implement their updated preauthorization and notification list for all commercial fully insured plans (HMOs, POS’, PPOs and EPOs) as well as the listing for Medicare Advantage plans. Precertification, preadmission, preauthorization and notification requirements all refer to the same process of authorization. Updates to the list [...]Tags: Healthcare Reform, Medical Billing
HUMANA – Compliance Training Reminder
October 22, 2012 – Humana is reminding providers to complete their 2013 Humana Compliance training and certification requirement. CMS requires that all Humana business associates, including health care providers, complete the training which includes Humana’s Compliance and Management Policy, Principles of Business Ethics and Fraud, as well as special needs plan training (required for family medicine, [...]Tags: Compliance, Healthcare Reform, Medical Billing, Medical Billing Compliance
Aetna & Cigna Announce More ACO Initiatives
October 22, 2012 – Both Aetna and Cigna recently announced more additions to their Accountable Care Organization (ACO) partnerships. Aetna contracted with North American Medical Management, California, Inc. (NAMM), a member of the Aveta Inc. family of companies, to set up a risk-shared accountable care collaboration and introduce PrimeCare Physicians Plans, an Aetna Whole Health [...]Tags: ACO, Affordable Care Act, Healthcare Reform, Medical Billing
Partial Code Freeze Prior to ICD-10 Implementation
October 8, 2012 – Included in the final ruling extending the transition of ICD-9 to ICD-10 coding to October 1, 2014, CMS also decided to extend the ICD-9/ICD-10 code freeze one additional year. The partial freeze will be implemented as follows: The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made [...]Tags: Anesthesia Billing, Anesthesia Coding, ASC Billing, ASC Coding, Coding, Medical Billing, Pathology Billing, Pathology Coding, Radiology Billing, Radiology Coding, Surgery Billing, Surgery Coding
CMS Delays Place of Service Policy until April 1, 2013
October 4, 2012 – We reported in our Quarterly newsletter last week that CMS would soon announce a delay in the effective date of their Place of Service (POS) policy. Yesterday , CMS released a revised transmittal pushing back the effective date from October 1, 2012 to April 1, 2013. The transmittal also added clarification to its [...]Tags: CMS Updates, Coding, Medical Billing, Pathology Billing, Pathology Coding, Radiology Billing, Radiology Coding
2013 CPT Codes Released by AMA
October 4, 2012 – The AMA, publisher of the annual CPT Code Book, recently released the 2013 Current Procedural Terminology (CPT) version. The book contains codes that will be used for claims filed as of service date January 1, 2013. The AMA states that the 2013 CPT codes will enhance the reporting of innovative diagnostic [...]Tags: 2013 CPT Codes, Anesthesia Billing, Anesthesia Coding, ASC Billing, ASC Coding, Coding, Medical Billing, Pathology Billing, Pathology Coding, Radiology Billing, Radiology Coding
Sequestration Is Very Real
October 4, 2012 – Remember last year when Congress’ Super Committee did not enact a plan to reduce the national debt by $1.2 trillion? Remember the 2% sequestration cut to Medicare payments that would result? Well, 2013 is the year the sequestration cut to Medicare payments will begin. This cut is in addition to the projected [...]Tags: ACA, Accountable Care Act, Healthcare Reform, SGR and Medicare Fee Schedule
Hospital Readmissions Reduction Program Begins
October 4, 2012 – On October 1, 2012, the ACA’s Hospital Readmissions Reduction Program begins. The program is an initiative that imposes financial penalties on more than 2,200 hospitals whose rates of Medicare readmissions are higher than the national average. Currently, CMS bases penalties on hospitals’ 30-day readmission rates for three illnesses – heart failure, [...]Tags: ACA, Affordable Care Act, CMS Updates, Compliance, Healthcare Reform
OIG 2013 Work Plan
October 4, 2012 – The Office of Inspector General’s (OIG) Work Plan publishes various projects to be addressed during the fiscal year by several government agencies, including the Centers for Medicare and Medicaid Services (CMS). The OIG reviews Medicare and Medicaid reimbursement and program integrity policies as well as Medicare Advantage and Medicare Part B [...]Tags: Advanced Diagnostic Imaging Billing, Anesthesia Billing, ASC Billing, Healthcare Reform, Medical Billing, Neurology Billing, OIG Workplan, Pathology Billing, Radiology Billing
2013 Proposed PQRS Measures
October 4, 2012 – The 2013 Proposed Medicare Physician Fee Schedule (MPFS) designates the PQRS, EHR and other incentive program quality measures that will be available in the 2013 program. Here is a quick heads-up on what may be coming down the pike for 2013. Remember: These are proposed provisions and will not be finalized [...]Tags: CMS Updates, EHR, eRx Incentive Program, Healthcare Reform, PQRS Incentive Program, SGR and Medicare Fee Schedule
Providers Must Revalidate Medicare Enrollment
October 4, 2012 - Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the Medicare revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result in [...]RAC Region C to Audit E/M Claims
September 24, 2012 – According to CMS, its recovery audit contractors (RACs) are scheduled to begin auditing claims that contain higher-level CPT codes for its evaluation and management (E/M) services based on recommendations from a report issued by the HHS Office of Inspector General in May 2012. The report, titled Coding Trends of Medical Evaluation [...]Tags: CMS Updates, Coding, Compliance, Medical Billing, Provider Enrollment, RAC Audits
CMS Announces Primary Care Practices to Participate in the Comprehensive Primary Care Initiative
September 5, 2012 – On August 22, 2012, CMS announced that 500 primary care practices in seven regions had been selected to participate in the Comprehensive Primary Care Initiative, a partnership between primary care providers and health insurers including, CMS, state Medicaid agencies, commercial health plans, and self-insured businesses. The practices were chosen based [...]Tags: ACO, CMS Updates, Healthcare Reform, Medical Billing
ICD-10 – Final Rule Issued
September 5, 2012 – On August 24, 2012, HHS issued the final rule concerning the transition from ICD-9-CM to ICD-10-CM diagnosis coding. As suggested in the proposed ruling in April 2012, HHS has finalized the year delay for the transition to ICD-10 coding from October 1, 2013 to October 1, 2014. Other options suggested by [...]Tags: Anesthesia Billing, ASC Billing, CMS Updates, Healthcare Reform, ICD-10, Medical Billing, Pathology Billing, Radiology Billing, Surgery Billing
EHR Stage 2 Final Rule Released
September 5, 2012 – On August 23, 2012, CMS announced the final rule for Stage 2 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The rule specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to successfully participate in the EHR [...]Tags: Anesthesia Billing, ASC Billing, CMS Updates, EHR, Meaningful Use, Medical Billing, Pathology Billing, Radiology Billing, Surgery Billing
EHR Stage 2 Ruling – Possible Exemptions for Anesthesiologists, Pathologists and Radiologists
September 5, 2012 – CMS has designated the specialties of anesthesiology, radiology and pathology as qualifiers for a new Scope of Practice exemption granted in the EHR Stage 2 ruling announced on August 23, 2012. This exemption is aimed at eligible professionals (EPs) who: lack both face-to-face interactions with patients, and lack the need [...]Tags: ASC Billing, CMS Updates, EHR, Healthcare Reform, Meaningful Use, Medical Billing, Pathology Billing, Radiology Billing
Last Chance to Begin 90-Day EHR Reporting Period for 2012
September 5, 2012 – Wednesday, October 3rd, is the last day for eligible professionals (EPs) to begin their 90-day consecutive reporting period in order to attest to meaningful use and be eligible to receive an EHR incentive payment for CY 2012. For EPs who have already completed their reporting period, CMS has a [...]Tags: EHR, Healthcare Reform, Meaningful Use, Medical Billing
Providers Must Revalidate Medicare Enrollment
September 5, 2012 – Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the Medicare revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result [...]Tags: CMS Updates, Medical Billing
Another Doc-Fix Bill Introduced to Congress
August 8, 2012 – On July 18, 2012, another bill, “Assuring Medicare Stability and Access or Seniors Act of 2012”, to avert the 27.4% SGR cut scheduled for January 1, 2013 was introduced to Congress by Rep. Michael Burgess, MD, (R-TX). The bill proposes freezing Medicare rates at their current level through 2013, postponing the [...]Tags: CMS Updates, Healthcare Reform, Medical Billing, SGR and Medicare Fee Schedule
New eRx Hardship Exemptions Proposed by CMS
August 8, 2012 – Included in the proposed 2013 Medicare Physician Fee Schedule (MPFS) were two additional significant hardship exemptions from the Medicare penalties for eligible professionals (EPs) who fail to be successful electronic prescribers under the Medicare Electronic Prescribing (eRx) Incentive Program. The proposed exemptions were meant to address the overlapping eRx requirements of [...]Tags: CMS Updates, EHR, eRx Incentive Program, Healthcare Reform, Medical Billing
CMS Begins Meaningful Use Audits
August 8, 2012 – CMS has contracted the firm of Figliozzi & Company of Garden City, NJ to perform audits of Medicare providers and dual-eligible Medicare and Medicaid Hospitals who have attested to having achieved EHR meaningful use (MU). Those being audited will receive a letter from Figliozzi and Co. with the CMS logo on [...]Tags: CMS Updates, EHR, Healthcare Reform, Meaningful Use
CMS announces 88 new Medicare ACOs
In July, CMS named an additional 88 Accountable Care Organizations (ACOs) to participate in its Medicare Shared Savings Program. Under the program, each organization agrees to be held accountable for reporting and adhering to quality measures for providing services to Medicare beneficiaries in return for the opportunity to share in any resulting cost savings with [...]Tags: ACO, CMS Updates, Healthcare Reform, Medical Billing
CMS finalizes new regulation to standardize electronic funds transfer
August 8, 2012 – CMS announced that the interim final rule that adopts healthcare electronic funds transfer (EFT) standards is now a final rule currently in effect. The final rule outlines two standards that health plans must comply with in order to use EFT to transmit healthcare claim payments to providers: Health plans are required [...]Tags: billing, CMS Updates, Medical Billing, Provider Enrollment
CMS Releases Provider Compliance Interactive Map
August 8, 2012 – In addition to the Provider Compliance Newsletter, on August 1,CMS released the Provider Compliance Interactive Map, a new tool for providers, billing companies and others. The purpose of the map and new webpage is to give information on the following Contractors: Payment Error Rate Measurement (PERM) Comprehensive Error Rate Testing (CERT) Medicare [...]Tags: CMS Updates, Compliance, Healthcare Reform, Medical Billing Compliance
Medicare Provider Compliance Newsletter
August 8, 2012 – CMS issues the “Medicare Quarterly Provider Compliance Newsletter,” a Medicare Learning Network® (MLN) educational product, to help providers understand the major findings identified by Medicare Administrative Contractors (MACs), Recovery Auditors, Program Safeguard Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as [...]Tags: CMS Updates, Compliance, Healthcare Reform
New Opportunity to Participate in the Advanced Payment Model
August 8, 2012 – In July, CMS announced the opportunity for smaller ACOs that are not affiliated with hospitals (other than critical access hospitals or small rural hospitals) to participate in the Advanced Payment Model program. Acceptable applicants will be: ACOs without any inpatient facilities and that have less than $50 million in total annual [...]Tags: Healthcare Reform, Medical Billing
Providers Must Revalidate Medicare Enrollment
August 8, 2012 – Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the Medicare revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result [...]Tags: CMS Updates, Medical Billing, Provider Enrollment
EMBLEM HEALTH UPDATES
Mandatory Enrollment of New York Homeless July 25, 2012 – The New York State Department of Health (NYSDOH) has begun mandatory enrollment of the New York City homeless population into Medicaid managed care. In New York City implementation began on April 1, 2012, and will continue in three phases over a six-month period, each targeting [...]Tags: Coding, Medical Billing, Radiology Billing, Radiology Coding
Aetna Updates for Specialists
Coding Policy Updates Duplex Scans Effective Date: 9/1/2012 93975 – Duplex Scan of arterial flow and venous outflow of abdominal, pelvic, scrotal contents and /or retroperitoneal organs; complete study. Aetna considers this code to be experimental and investigational for the assessment of average-risk or high-risk pregnancies. Claims will deny when billing this code. Coverage criteria [...]Tags: billing, Coding, Medical Billing, Neurology Billing
Cigna Updates
Timely Filing of Claims Effective Date:August 1, 2012 Unless an longer time period is required by applicable state law, the time frame to submit claims will change to 90 days for participating health care professionals who have received a notification and an amendment to their agreement in these affected states: DC, FL, MD, NC, NJ, [...]Tags: billing, Coding, Medical Billing
Supreme Court Upholds the ACA
July 5, 2012 – As we all know the Supreme Court upheld most of the Patient Protection and Accountable Care Act, otherwise known as the Accountable Care Act (ACA). The Court rendered their decision on the constitutionality of the individual mandate and the Medicaid expansion provision. The Court ruled that the law’s individual mandate is [...]Tags: ACO, Healthcare Reform, Medical Billing
AMA Releases Insurance Company Report Card
July 5, 2012 – In June, the AMA released their 2012 National Health Insurer Report Card (NHIRC) at it’s annual meeting. The NHIRC provides metrics on the timeliness, transparency and accuracy of claims processing of health insurance payers in an effort to educate physicians and the public, and to reveal opportunities for improvement. The report [...]Tags: Medical Billing
EHRs – Use of Patient Work Information
July 5, 2012 – The National Institute for Occupational Safety and Health (NIOSH), part ofHHS’ Centers for Disease Control and Prevention which works to promote and protect population health, believes clinicians should have a better understanding of work-related conditions so they can identify and prescribe effective treatment and prevention strategies. The NIOSH is requesting input [...]Tags: EHR, Meaningful Use, Medical Billing
CMS Establishes New Data Services Office
July 5, 2012 – CMS has established its Office of Information Products and Data Analysis (OIPDA), which will oversee the agency’s portfolio of data and information. OIPDA will be responsible for making the development, management, use, and dissemination of data and information resources into one ofvCMS’ core functions as well as administer a new initiative [...]Tags: Healthcare Reform, Medical Billing
Expansion of Women’s Preventive Services
July 5, 2012 – The Affordable Care Act (ACA) requires health plans to cover recommended preventive services without cost-sharing. Currently, preventive services such as mammograms and screenings for cervical cancer, are already covered with no cost-sharing for new health plans. Last August, the U.S. Department of Health and Human Services (HHS) adopted additional guidelines for [...]Tags: Healthcare Reform, Medical Billing
Highmark BCBS (PA) – Begins ICD-10 Coding
June 20, 2012 – Highmark Blue Cross Blue Shield is beginning to include ICD-10-CM diagnosis codes on its Highmark medical policies during 2012. These ICD-10-CM diagnosis codes are being added for information purposes only in preparation for the transition to ICD-10-CM.Tags: Coding, ICD-10, Medical Billing
Horizon & Highmark BCBS Buy NaviNet
June 20, 2012 – Earlier this year, Horizon BCBS in partnership with Highmark, Inc., Independence Blue Cross and health information technology provider, Lumeris, Inc, purchased NaviNet®. NaviNet was the largest real-time communication network for physicians, hospitals and health insurers. This new partnership will build on NaviNet’s network for transactions among health care professionals and health [...]Tags: ACO, Healthcare Reform, Medical Billing
AMA Introduces 5-Year Payment Plan
June 20, 2012 – During the opening day of the annual AMA House of Delegates meeting, the AMA Executive Vice President and CEO Dr. James Madara proposed the organization’s “rolling” five-year plan for reforming Medicare payment. The plan will focus on three targets: improving health outcomes, accelerating change in medical education and shaping delivery and payment models that [...]Tags: Healthcare Reform, Medical Billing, SGR and Medicare Fee Schedule
More Than 100,000 Health Care Providers Paid for EHR MU
June 20, 2012 – The Department of Health and Human Services (HHS) recently announced that the Medicare EHR Incentive Program has paid out more than $3.7 billion through May of this year to providers who have attested that they have met federal criteria for meaningfully using certified EHR systems. The State Medicaid programs have paid out more than [...]Tags: EHR, Meaningful Use, Medical Billing
eRx Incentive Program – Last Chance to Avoid the 2013 Payment Penalty – Deadline is June 30, 2012
June 20, 2012 – Please be reminded that if you were not a successful e-prescriber last year by submitting 25 e-prescribe encounters (between January 1, 2011 – December 31, 2011), you may still qualify and avoid the 2013 1.5% payment adjustment by; Submitting at least 10 e-prescribe encounters via code G8553 for service dates betweenJanuary [...]Tags: eRx Incentive Program, Medical Billing
Providers Must Revalidate Medicare Enrollment
June 20, 2012 – Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the Medicare revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result [...]Tags: Medical Billing, Provider Enrollment
Medical Organizations Again Request for SGR Repeal
June 5, 2012 – MGMA-ACMPE (Medical Group Management Association) and the AMA wrote letters in response to the House Ways and Means Committee’s request for comments on alternative approaches to the current Medicare payment system. The MGMA, in its 6-page letter, stated that according to their data, they projected the total operating cost per full-time [...]Tags: ACO, Healthcare Reform, SGR and Medicare Fee Schedule
Comprehensive Primary Care Initiative (CPC)
June 5, 2012 – On April 11, 2012, CMS’ Innovation Center announced that the CPC, the a multi-payer initiative fostering collaboration between public and private health care payers to strength primary care has chosen the following areas to represent their selected markets. The markets are multi-payer and may include private health plans, state Medicaid agencies and [...]Tags: ACO, CMS Updates, Healthcare Reform
CMS Announces New Comparative Billing Reports (CBRs) to Providers
June 5, 2012 – CMS has recently announced three new reports comparing select providers with their peers. The reports were or will release them on the following dates: May 21, 2012– Family Practice and Internal Medicine physicians performing certain cardiology services June 4, 2012- CMS will release 5,000 Comparative Billing Reports for primary care providers [...]Tags: CMS Updates, Healthcare Reform
Physician Compare – New Group Practice Option
June 5, 2012 – CMS has enhanced their Physician Compare website based on recommendations made during testing as well as suggestions from users and stakeholders. The new feature is a Group Practice option including Search, Compare and Profile pages. These features allow users to search by Group Practice name, get maps and directions, and do [...]Tags: CMS Updates, Healthcare Reform
House of Representatives Continues to Seek Repeal of the ACA
June 5, 2012 – Since the Republicans took control of the House of Representatives in January, 2011; they have passed a series of bills aimed at the repeal or all or parts of the Patient Protection and Affordable Care Act (ACA). On Thursday, May 31, theHouse Waysand Means Committee approved three bills that repealed or [...]Tags: Healthcare Reform, Medical Billing
Legislation Introduced to Repeal SGR
May 17, 2012 – Last week, Allyson Schwartz (D-PA) and Joe Heck (R-Nev), introduced bipartisan legislation, The Medicare Physician Payment Innovation Act (PDF), that would repeal the SGR and avert a more than 30% payment reduction to physicians next January. Their plan would: Freeze payments to physicians at the 2012 levels throughDecember 31, 2013 Provide [...]Tags: Medical Billing, SGR and Medicare Fee Schedule
AMA and Medical Societies Submit Numerous Comments to Proposed Stage 2 Rule
May 17, 2012 – On the same day as the comments were due for Stage 2 Meaningful Use, May 7, 2012, the AMA and 98 other medical societies sent a 37 page comment letter to CMS stating that their Stage 2 proposed rules for “meaningful use” would discourage more than encourage providers to participate in the [...]Tags: EHR, Healthcare Reform, Meaningful Use
CMS Issues More Time to Enroll in Medcare
May 17, 2012 - CMS, after considerable pressure from the Health Business Management Association (HBMA) has announced a change in their enrollment process that will allow providers to enroll in Medicare up to 60 days prior to their start date. Until now, providers were prohibited from enrolling in Medicare more than 30 days prior to their [...]Tags: CMS Updates, Provider Enrollment
Primary-Care Physicians May See increase in Medicaid rates
May 17, 2012 – Over the next two years, $11 billion will be distributed to States to use for increasing the reimbursement of primary care services. This new proposed rule will increase average Medicaid primary care payments by 34% according to one estimate cited by CMS. The increased payments will be made to encourage primary [...]Tags: CMS Updates, Healthcare Reform
Senate Proposes Halt to MPPR cuts
May 3, 2012 – On April 25, Senators Ben Cardin (D-MD) and David Vitter (R-LA) introduced legislation, bill S. 2347, “The Diagnostic Imaging Services Access Protection Act of 2012,” which would stop CMS from implementing a 25% reduction to the professional component of diagnostic imaging services for multiple imaging studies administered to the same patient, [...]Tags: Medical Billing, SGR and Medicare Fee Schedule
CMS Proposes ICD-10 Delay Until October 1, 2014
May 1, 2012 – On April 9, 2012, the Department of Health and Human Services (HHS) announced a proposed rule to delay the implementation of ICD-10 diagnosis coding until October 1, 2014, a full year later than the original deadline announced in 2009. The new ICD-10 compliance date is part of a 198-page proposed rule [...]Tags: ICD-10, Medical Billing
eRx Incentive Program – Two Chances to Avoid the 2013 Payment Penalty – Deadline is June 30, 2012
May 1, 2012 – Please be reminded that if you were not a successful e-prescribe subscriber last year by submitting 25 e-prescribe encounters (between January 1, 2011 – December 31, 2011), you may still qualify and avoid the 2013 1.5% payment adjustment by: Submitting 10 e-prescribe encounters via code G8553 for service dates betweenJanuary 1, [...]Tags: eRx Incentive Program, Medical Billing
REMINDER: Providers Must Revalidate Medicare Enrollment
May 1, 2012 – Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result in [...]Tags: Medical Billing, Provider Enrollment
CMS Publishes Final Rule on Ordering, Referring and Documentation Requirements
May 1, 2012 – On April 27, 2012, CMS published the final rule “Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements.” The rule was established under the Affordable Care Act and was implemented in the interim final rule with comment period on [...]Tags: Healthcare Reform, Medical Billing, Provider Enrollment
Final HIPAA/HITECH Rule Arrives at the OMB
May 1, 2012 – On March 24, The Office of Civil Rights submitted “Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules” as a final rule to the White House Office of Management and Budget (OMB). The OMB review is typically the last step in the federal rulemaking process before the official publication [...]CMS Posts Stage 2 Quality Measures
April 24, 2012 – Recently, CMS posted the proposed Stage 2 clinical quality measures in a downloadable spreadsheet format. One sheet is for physicians and other eligible professionals and the other is for hospitals. You can view the physician sheet here – Proposed Stage 2 Quality Measures The public comment period on the Stage 2 [...]Tags: EHR, Meaningful Use
CMS Selects 27 Participants for the Medicare Shared Savings Program
April 24, 2012 - On April 10, 2012, CMS announced that 27 healthcare entities in 18 states have entered into agreements to become the first Medicare Shared Savings Program accountable care organizations. This brings the total number of organizations participating in the Medicare shared savings initiatives to 65, including the 32 Pioneer ACO and 6 Physician [...]Tags: ACO
HHS PROPOSES ONE-YEAR DELAY OF ICD-10 COMPLIANCE DATE
April 9, 2012 – This announcement was taken from the CMS website. HHS released this announcement today. Action The Department of Health and Human Services (HHS) today announced a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and [...]Tags: ICD-10
New Initiative to Bolster Primary Care Workforce
April 4, 2012 – On Wednesday, March 21, CMS announced a call for applications for a new ACA initiative designed to strenghten primary care. Under the graduate nurse education demonstration, CMS will provide hospitals working with nursing schools to train advanced practice registered nurses (APRNs) with payments of up to $200 million over four years to [...]Tags: Healthcare Reform
House Votes Down IPAB
April 4, 2012 – On Thursday, March 29, the House voted to repeal the Independent Payment Advisory Board (IPAB) for Medicare and to restrict medical malpractice lawsuits limiting the amount of damages awarded to $250,000. The bill is likely dead on arrival in the Senate, and the White House has announced it will veto the bill if it does [...]Tags: Healthcare Reform
CMS Pushes Back Enforcement of 5010 Implementation Again
April 4, 2012 – In mid-March CMS announced it would again push back the enforcement of 5010 for another three months, until June 30. The original date of 5010 implementation was January 1, 2012, followed by a push back to March 31, 2012. The MGMA had petitioned CMS to again push back the date [...]Tags: Healthcare Reform
The Affordable Care Act (ACA) Goes to Court
April 4, 2012 – Days after the ACA’s second anniversary, the Supreme Court heard three days (March 26-March 28) of oral arguments concerning its constitutionality. Twenty-six states sued the federal government primarily over the constitutionality of the minimum essential coverage provision, which requires that nearly everyone is required to have health insurance starting in 2014 [...]Tags: Healthcare Reform
CMS Delays Place of Service (POS) Policy to October 1, 2012
April 4, 2012 – In our February Insurance Updates newsletter we reported that on February 3, 2012, CMS issued a new transmittal 2407 updating their instructions for reporting the place of service (POS) when billing claims to Medicare for services paid under the Medicare Physician Fee Schedule (MPFS). The instructions were to be implemented on [...]Tags: CMS Updates
CMS May Give Second Chance on 2012 Penalty Adjustments
April 4, 2012 – Physicians who were not deemed “successful electronic prescribers” in 2011 have recently received letters from CMS informing them of their status. CMS has also notified physicians who sought a hardship exemption whether their application was approved, although there are still some notifications of the hardship exemption still pending at CMS. [...]Tags: eRx Incentive Program
PQRS & eRx 2012 Incentive Programs
April 4, 2012 – A new year to report PQRS and eRx measures began January 1, 2012. If you have not yet chosen to participate in these programs in 2012 and want to earn an incentive and avoid a 2014 payment reduction, you must begin participation as soon as possible. PQRS Incentive Program - The [...]Tags: eRx Incentive Program
eRx Incentive Program – Two Chances to Avoid the 2013 Penalty
April 4, 2012 – CMS is offering 2 ways to avoid the eRx penalty in 2013, if you did not qualify as a successful e-precribe provider last year. Submit 10 E-Prescribe Encounters Before June 30, 2012 CMS is giving eligible providers another chance to avoid the 2013 payment adjustment of 1.5%. If you did not qualify [...]Tags: eRx Incentive Program
HHS Issues Final Health Insurance Exchange Rules
March 15, 2012 Effective Date: January 1, 2014 On March 12, 2012, HHS issued the Final Interim Rule implementing the state health insurance exchanges mandated by the Affordable Care Act (ACA). The Exchanges are designed to provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options on the [...]Tags: Healthcare Reform
Medicare Revalidation
March 15, 2012 – Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result in [...]Tags: CMS Updates
Repeal of IPAB To Be Attached to House Tort Reform Bill
March 15, 2012 – Next week, House members are expected to vote on a medical liability reform bill that includes language to repeal the ACA’s (Accountable Care Act)IPAB (Independent Payment Advisory Board). The bill is called the Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act of 2011 and calls for capping punitive damages in healthcare lawsuits to [...]Tags: Healthcare Reform
AMGA Suggests Alternatives to SGR Formula
March 15, 2012 – The public policy team of the American Medical Group Association (AMGA) told attendees at the AMGA’s annual conference in San Diego that they are advocating for two alternatives to the SGR formula and offered a suggestion for what they could do to get Congress moving on repealing the SGR. The AMGA said [...]Tags: SGR and Medicare Fee Schedule
CMS announces Proposed Rule for STAGE 2 Use of Certified EHR Technology
March 2, 2012 – On February 23, 2012, CMS announced their proposed ruling for Stage 2 Requirements under the Medicare and Medicaid Electronic Health Record Incentive Programs. Although much of Stage 2 is an extension of Stage 1, there are proposals in Stage 2 that are a direct result of medical organizations responding to the [...]Tags: EHR, Meaningful Use
Office of the National Coordinator (ONC) Issues Proposed Stage 2 Ruling
March 2, 2012 – The day after CMS announced their Stage 2 ruling, ONC issued its companion proposed Stage 2 ruling on February 24. The HITECH Act directs ONC to support and promote meaningful use of Certified EHR Technology (CEHRT) nationwide through the adoption of standards, implementation specifications, and certification criteria as well as the establishment [...]Tags: EHR, Meaningful Use
CMS Proposes New Overpayment Rule
March 2, 2012 – CMS has proposed a new rule under the Patient Protection and Affordable Care Act, that will require healthcare providers to return any Medicare overpayments within 60 days after erroneous payments were detected. Previously, hospitals and other providers did not face an explicit deadline for returning the overpayment, but now any failure to [...]Tags: CMS Updates
Medical Organizations Support Bill to Repeal IPAB
March 2, 2012 – The House Energy and Commerce Committee’s health subcommittee voted yesterday to repeal the Independent Payment Advisory Board (IPAB) created under the Affordable Care Act (ACA). The legislation will now move to the full committee for consideration. Sen. John Cornyn (R-Texas) reintroduced legislation last week which would also eliminate the IPAB. Unless [...]Tags: Healthcare Reform
President Obama signs Medicare Physician Payment Extension into Law
March 2, 2012 – President Obama signed the “Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act)” into law, averting a 27 percent cut to Medicare physician payments through 2012. Much of the medical community continues to urge Congress to repeal once and for all the sustainable growth rate formula [...]Tags: SGR and Medicare Fee Schedule
Congress Extends SGR
February 21, 2012 – On February 17, The House and Senate have both voted to approve legislation preventing the scheduled 27.4%SGRrelated cut from taking effect on March 1. The legislation goes to the President who has indicated that he will sign the bill. Below is a recap of all of the health provisions included in [...]Tags: SGR and Medicare Fee Schedule
CMS Has Updated the EHR Information Center with New Self-Service Options
February 16, 2012 – CMS has announced that the Electronic Health Record (EHR) Information Center Interactive Voice Response (IVR) system has been enhanced to provide users with an increased number of options and services to make accessing and reviewing data easier. Providers can now obtain information through an extensive IVR Self-Service option. ID. This newly [...]Tags: EHR, Meaningful Use
All Medicare Provider Payments To Be Made By Electronic Funds Transfer
February 16, 2012 – Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change request, or revalidation; providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). As part of CMS’s revalidation efforts, all [...]Tags: Healthcare Reform
CMS Issues New Place-of-Service Code (POS) Instructions
February 16, 2012 – On February 3, 2012, CMS issued a new transmittal (CR7631) updating their instructions for reporting the place of service (POS) when billing claims to Medicare for services paid under the Medicare Physician Fee Schedule (MPFS). The new transmittal establishes that for all services paid under the MPFS, with two exceptions, [...]Tags: CMS Updates
Reminder: Providers Must Revalidate Medicare Enrollment
February 16, 2012 - Between now and March 2015, Medicare contractors (MACs) will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process. In most cases, these notices will be sent directly to the provider and not to AHS. Failure to complete and submit the enrollment form may result in the [...]Tags: Provider Enrollment
SGR Update
February 16, 2012 – Yesterday, House and Senate negotiators reached a temporary agreement on freezing the current SGR rate for 10 months, avoiding the 27.4% cut in Medicare reimbursement scheduled for March 1, 2012. The 20-member bipartisan House-Senate conference committee has been meeting for the past month to come to an agreement on the SGR rate along [...]Tags: SGR and Medicare Fee Schedule
SGR Update
February 1, 2012 Congressional Update After the failure of last year’s “super” committee, a new bipartisan committee, The House-Senate Conference Committee, was formed as part of the bill passed before Christmas extending payroll tax cuts and postponing Medicare reimbursement cuts for two months. The new committee is tasked with agreeing on a year-long payroll [...]Tags: SGR and Medicare Fee Schedule
Medicare- Provider Participation Enrollment Deadline Extended
February 1, 2011 – On December 22, 2011, CMS announced that it would extend the 2012 Annual Participation Enrollment Period for providers until February 14, 2012. Physicians have until that time to determine their Medicare participation status for 2012. The effective date for any participation status change during the extension, remains January 1, 2012, and [...]Tags: Provider Enrollment
HHS Publishes New Medicaid Quality Measures
February 1, 2011 – HHS has released a set of 26 quality measures that will eventually be used to determine the quality of care that adult Medicaid patients are receiving in each state. The measures are part of the Affordable Care Act (ACA) which mandated a Medicaid Quality Management Program be established to fund development, testing, [...]Tags: Healthcare Reform
HHS Releases Guidance on proposed “Essential Health Benefits”
February 1, 2012 – On December 15, 2011, HHS released guidance outlining their proposed policies for implementing “essential health benefits” (EHB), including those health plans participating in health insurance exchanges beginning in 2014. The policies are mandated by the Affordable Care Act and define the minimum package of benefits that certain health plans must cover, [...]Tags: Healthcare Reform
Reminder to Participate in CMS Incentive Programs
January 23, 2012 – A new year to report PQRS and eRx measures began January 1, 2012. If you have not yet chosen to participate in these programs and want to earn incentives or avoid a payment reduction, you must begin participation as soon as possible. eRx (e-prescribe) Program Not participating in this program [...]Tags: Healthcare Reform
Pre-certification, Notification and Prior Authorizations for 2012
January 23, 2012 – With the many changes in CPT codes for 2012, please be aware of new codes that will be added to insurance carriers’ Advanced Imaging Notification and Prior Authorization and Pre-certification lists. Many of the new codes replaced the deleted 2011 codes on those lists or they may be totally new codes. [...]Tags: CMS Updates
HHS Issues Rule on Electronic Payments from Insurers
January 23, 2012 – On January 5, the Department of Health and Human Services (HHS) released a final rule on the electronic transfer of funds (EFTs) between insurers and healthcare providers that the agency says will save billions of dollars and millions of pounds of paper. This ruling was part of the Affordable Care [...]Tags: Healthcare Reform
CMS Innovation Advisors Program
January 5, 2012 – CMS has chosen 73 healthcare professionals out of 920 applications to participate in their Innovation Advisors Program. The intention of the program is to create a network of experts that will work towards improving the delivery system for Medicare, Medicaid and CHIP beneficiaries. These advisors come from 27 states and Washington, DC, and [...]Tags: Healthcare Reform
CMS Publishes 2012 ICD-10 CM Code Updates
January 5, 2012 – In December, CMS posted the 2012 ICD-10-CM code updates to their website, including the 2012 ICD-10-CM index and tabular, code titles, addendum, GEMs and reimbursement mapping files. You may access this information by clicking below and scrolling to the DOWNLOAD section. CMS ICD-10 GuidelinesTags: ICD-10
2012 Enrollment Application Fee for Institutional Providers
January 5, 2012 – The CMS Enrollment Application fee for institutional providers for 2012 is $525.00, up from $505.00 in 2011. CMS has defined “institutional provider” to mean any provider or supplier that submits a paper Medicare enrollment application using CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S forms or associated Internet-based PECOS [...]Tags: Provider Enrollment
32 Organizations are Named to Participate in the Pioneer ACO
January 5, 2012 – In mid-December, the Department of Health and Human Resources (HHS) revealed the 32 organizations chosen to participate in the Pioneer ACO model. 80 applicants had applied for the program, with 160 letters of intent. According to HHS, the Pioneer ACO model will test the effects of several payment arrangements to support [...]Tags: Healthcare Reform
Extension of the 2011 Physician Payment Rates and other Policies
January 5, 2012 – On December 23, 2011, President Obama signed the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA). The TPTCCA included the extension of the 2011 Medicare physician fee schedule (MPFS) by postponing the SGR reduction of 27.4 percent through the month of February. While the physician fee schedule will be [...]Tags: SGR and Medicare Fee Schedule
New HIPAA Audit Program
December 8, 2011 – The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has introduced the The Pilot Audit Program to perform up to 150 audits of compliance with the privacy, security and breach notification standards adopted under HIPAA. The program will only audit HIPAA-covered entities (health care providers, health plans [...]Tags: Healthcare Reform
OIG’s 2012 Work Plan
December 8, 2011 – The following are some of the areas to be reviewed by the Office of Inspector General (OIG) as part of their Work Plan for 2012 that may affect your practice. In addition to those areas, the following general reviews will be performed by the agency. A copy of the entire 2012 [...]Tags: Healthcare Reform
CMS Pushes Back Enforcement of 5010
December 8, 2011 – On November 17, 2011, CMS announced that it is giving healthcare providers, private insurers, and go-between companies until March 31, 2012 to switch to the new 5010 standards for electronic claims. Implementation of 5010 presents substantial changes to the content on electronic claims as well as the data available to providers [...]Tags: Healthcare Reform
Congress May Address 2012 SGR Next Week
December 8, 2011 – Last week, House Majority Leader Eric Cantor (R-VA) stated that Congress would pass legislation by December 16, to avert the 27.5% reduction of Medicare reimbursement to physicians. As quoted in Medscape Medical News, Rep. Phil Roe, MD (R-TC), vice chair of the GOP Doctors Caucus in the House, stated that legislation on [...]Tags: SGR and Medicare Fee Schedule
Key Points of the 2012 Medicare Physician Fee Schedule – Final Rule
The 2012 Medicare Physician Fee Schedule Final Rule with comment period was released by the Department of Health & Human Services (HHS) and the Center for Medicare and Medicaid Services (CMS) on November 1, 2011. This special edition newsletter presents the finalized provisions that may affect your medical practice. You may access this final rule in [...]Tags: SGR and Medicare Fee Schedule
AMA Votes to Stop the Implementation of ICD-10
November 11, 2011 – The AMA, on the last day (November 15) of their semi-annual meeting, voted to “work vigorously to stop implementation of ICD-10” which is set to begin on October 1, 2013, citing the healthcare industry’s full plate of changes and reforms, including the federal push for electronic health records. “The implementation [...]Tags: ICD-10
Supreme Court to Hear Healthcare Reform Law
November 17, 2011 – On Monday, the Supreme Court announced it will hear the case that originated in Florida, in which 26 states are suing the federal government challenging the individual provision of the Affordable Healthcare Act, (ACA) which mandates that nearly everyone must have health insurance by 2014, or else face a tax penalty [...]Tags: Healthcare Reform
CMS Extends Timeframe for Provider Re-Validation and Provides Physician List
November 14, 2011 – As we have reported in several of our newsletters, all providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (ACA). CMS originally set out to send re-enrollment [...]Tags: Provider Enrollment
Comprehensive Primary Care Initiative (CPC)
November 3, 2011 – The CPC is a new CMS-led, (through their Innovation Center), multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care services, which CMS states has been historically under-funded and under-valued in the US. CMS will be soliciting other payers, including Medicaid, that are currently providing or willing [...]Tags: Healthcare Reform
Advanced Payment Model for ACOs
November 3, 2011 – The Advanced Payment Model is an Innovation Center initiative designed for participants in need of prepayment of expected shared savings to build their accountable care organization under the Medicare Shared Savings Program (SSP). This program is designed to test whether and how pre-paying a portion of future shared savings could increase [...]Tags: Healthcare Reform
The House Votes to Repeal the 3% Withhold Law
November 3, 2011 – On Thursday, October 27, the House passed a bill by 405-16 to rescind the yet-to-be implemented 3% Medicare withholding rule. Health care organizations had actively encouraged Congress to either repeal the law entirely or, at a minimum, repeal the law as it relates to Medicare payments. Under the proposed law, CMS would [...]Tags: SGR and Medicare Fee Schedule
Self Referral/Anti-Kickback Waivers for ACOs Issued
November 3, 2011 – In conjunction with the release of the ACO Final Rule, CMS, the Office of Inspector General (OIG) and the Department of Health & Human Services (HHS), issued an “interim final rule with comment” that establishes waivers to the physician self-referral law, the federal anti-kickback statute, and certain civil monetary penalties law [...]Tags: Healthcare Reform
CMS Issues ACO Final Rule
November 4, 2011 – The long-awaited Final Rule for Medicare accountable care organizations (ACOs) (Section 3022 of the Accountable Care Act (ACA)) was published on October 20, 2011, establishing CMS’ definition of Medicare’s ACO and Shared Savings Program (SSP). CMS Administrator, Dr. Donald Berwick, stated that the proposed rule, issued on March 31, 2011, generated [...]Tags: Healthcare Reform
Radiology Assistants May Bill Medicare in the Near Future
October 7, 2011 – A bill letting facilities and radiology groups bill Medicare for imaging services performed by certified radiology assistants is currently in Congress. The “Medicare Access to Radiology Care Act of 2011″ would amend the Social Security Act to recognize radiologist assistants as non-physician providers of healthcare services to Medicare beneficiaries as well as reimburse [...]Tags: CMS Updates
Patients May Now Access Test Reports Directly From Labs
October 7, 2011 – On September 14, 2011, HHS proposed new rules that would expand patients’ rights to access their health care information. The proposed new rules would allow patients to access their test results directly from laboratories by request. The rules would ensure that labs covered under HIPPA readily provide the requested information to [...]Tags: CMS Updates
HHS Implements RAC Audits for Medicaid
October 7, 2011 – On September 14, HHS (Dept. of Health & Human Services) issued a final rule to establish a Medicaid Recovery Audit Contractor Program that will go into effect as of January 2, 2012. The Medicaid RAC program, which will be modeled after the Medicare RAC program, was mandated by the Affordable Care Act to [...]Tags: RAC Audits
Medicare RAC Changes Issuance of Demand Letters
October 11, 2011 – On January 3, 2012, CMS will transfer the responsibility for issuing RAC demand letters to providers from its Recovery Auditors to its Medicare claims processing contractors in order to avoid delays in demand letter issuance. This will mean that when a Recovery Auditor finds that improper payments have been made to [...]Tags: RAC Audits
MedPAC Votes on SGR Repeal
October 7, 2011 – On October 6, 2011, the Medicare Payment Advisory Commission (MedPAC) officially endorsed a plan to repeal the SGR (sustainable growth rate) payment formula. Despite outcries from the physician community, MedPac submitted their original proposal to pay for the repeal of the SGR by freezing the reimbursement rate for primary care physicians for [...]Tags: SGR and Medicare Fee Schedule
CMS Establishes Web Tool to report eRx Hardships
October 11, 2011 – On August 31, 2011, CMS released the final rule for the eRx program, which included additional hardship exemptions for the 2011 calendar year for purposes of the 2012 payment adjustment. As part of the request for hardship exemptions, EPs (eligible professionals) must submit their hardship requests via CMS’ web tool, the [...]Tags: eRx Incentive Program
Reminder: Deadline to File eRx Hardship Letter
October 11, 2011 – This is a reminder that the deadline to request a hardship exemption for the 2012 Medicare Electronic Prescribing (eRx) Incentive Program adjustment for Calendar Year 2011 is November 1, 2011. See the next article in this issue on how to apply for the exemption(s). The following are CMS’ approved hardship exemptions. Limited [...]Tags: eRx Incentive Program
Proposed 2012 Medicare Physician Fee Schedule and Deficit Reduction Plan
October 5, 2011 – The proposed Medicare Physician Fee Schedule (MPFS) rule was issued on July 1, 2011 with public comments ending on August 31. The proposed 2012 estimated conversion factor will be $23.9635, a 29.5 percent reduction from 2011. It is expected that the MPFS final rule will be issued by November 1, 2011 [...]Tags: SGR and Medicare Fee Schedule
Suggestions for Repealing the SGR Rate
October 5, 2011 – Both Democrats and Republicans acknowledge that the Medicare physician payment system is broken and a permanent “fix” must be established. The problem, of course, is to come up with a plan to replace the SGR payment formula before the 29.5 percent payment reduction takes place on January 1, 2012. It is [...]Tags: SGR and Medicare Fee Schedule
HHS Awards Grants to sign up Children for Health Coverage
September 7, 2011 – On August 18, 2011, the U.S. Department of Health and Human Services (HHS) announced $40 million in grants to identify and enroll children for Medicaid and the Children’s Health Insurance Program (CHIP). Grants were awarded to 39 state agencies, community health centers, school-based organizations and non-profit groups in 23 states. CMS [...]Tags: Healthcare Reform
CMS Launches “Bundled Payment Plan”
September 7, 2011 – On August 23, 2011, CMS’ Center for Medicare and Medicaid Innovation (Innovation Center), as required by the Affordable Care Act (ACT), launched the “Bundled Payment Plan,” a voluntary program that bundles Medicare payments to hospitals, physician groups, non-physician practitioners, and other entities to encourage care coordination and cost reduction beginning in [...]Tags: Healthcare Reform
Medicare Providers Must Revalidate Enrollment
September 7, 2011 – All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (ACA). We reported this new regulation in our Leading Edge newsletter, Volume CN9, on April 20, 2011. You [...]Tags: Provider Enrollment
CMS Announces Changes to the Medicare eRx Incentive Program for Calendar Year 2011
September 7, 2011 – Since publication of the 2011 MPFS (Medicare Physician Fee Schedule) Final Rule, CMS received many public comments concerning the eRx Incentive Program which resulted in CMS revising some of the provisions of the eRx program. On August 31, 2011, CMS announced the following changes to the Medicare Electronic Prescribing (eRx) [...]Tags: eRx Incentive Program
CMS Issues 2010 eRx Incentive Payments
September 7, 2011 – On August 17, 2011, CMS announced that they would soon begin issuing incentive payments for the 2010 Medicare Electronic Prescribing (eRx) Incentive Program for eligible professionals (EPs) who met the criteria for successful reporting. Distribution of payments for the eRx Incentive Program was scheduled to be completed by August 31, 2011. [...]Tags: eRx Incentive Program
CMS Releases New ABN (Advanced Beneficiary Notice of Non-Coverage) Form
September 7, 2011 – CMS has issued a new ABN form (CMS-R-131) that is to be used by physicians, practitioners, independent laboratories and suppliers in situations where Medicare payment is expected to be denied. The new form will contain the date 3/2011 in the lower left hand corner. Providers should begin to use these forms [...]Tags: CMS Updates
Obama administration offers states new ways to improve care, lower costs for Medicaid
August 4, 2011 – States and the federal government spend more than $300 billion each year to care for Americans eligible for Medicare and Medicaid. In Medicaid, these individuals represented 15-percent of enrollees and 39-percent of all Medicaid expenditures. In Medicare, they represented 16-percent of enrollees and 27-percent of program expenditures. Three new initiatives [...]Tags: Healthcare Reform
New Private Nonprofit Health Plans Will Increase Competition, Give Consumers and Small Businesses More Health Insurance Choices
August 4, 2011 – On July 18, CMS took steps to encourage the creation of Consumer Operated and Oriented Plans (CO-OPs), new private non-profit, consumer-governed health insurance plans that CMS states will help increase competition and give consumers and small businesses additional affordable health insurance choices. CMS is proposing standards for CO-OPs, and for qualifying [...]Tags: Healthcare Reform
HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress
Auguat 4, 2011 – On July 11, HHS proposed a framework to assist states in building Affordable Insurance Exchanges, state-based competitive marketplaces where individuals and small businesses will be able to purchase affordable private health insurance and have the same insurance choices as members of Congress. Starting in 2014, Exchanges will make it easy [...]Tags: Healthcare Reform
Partnership for Patients Meets Goal of Over 2,000 Participating Hospitals
August 5, 2011 - HHS’ Secretary Kathleen Sebelius announced on July 8 that nearly 4,500 organizations — including over 2,000 hospitals — have pledged their support for the Partnership for Patients, the new nationwide patient safety initiative. In less than three months, the Obama Administration has met its goal of having 2,000 hospitals pledge their support. [...]Tags: Healthcare Reform
Four More States launch Medicaid EHR Incentive Program
August 4, 2011 – On July 4th, the Medicaid Electronic Health Record (EHR) Incentive Program was launched in Arizona, Connecticut, Rhode Island, and West Virginia. This means that eligible professionals and eligible hospitals in these four states will be able to complete their EHR Incentive Program registration at the state level and receive incentive payments. [...]Tags: EHR, Meaningful Use
Medicaid will no Longer Pay for Preventable Events
July 20, 2011 – In late May, CMS passed a final rule announcing that hospitals and healthcare providers will no longer be reimbursed for treating their Medicaid patients for illnesses, injuries, or readmissions that should have been prevented. This rule enacts a portion of the Affordable Care Act (ACA) that prohibits States from making [...]Tags: CMS Updates
CMS Proposes to Release Medicare Data to Rank Physicians
July 6, 2011 – On June 2, 2011 CMS released proposed rules, as part of the Affordable Care Act (ACA), to allow organizations that meet certain qualifications access to patient-protected Medicare data. These organizations will produce public reports on physicians, hospitals and other health care providers to identify which hospitals and doctors provide the highest [...]Tags: Healthcare Reform
CMS Releases First Results of Preventive Care Initiative
July 6, 2011 – On June 20, CMS released a report showing that more than 5 million Americans with traditional Medicare – or nearly one in six people with Medicare – took advantage of one or more of the recommended preventive benefits now available for free under the Affordable Care Act. (ACA). The most popular [...]Tags: Healthcare Reform
New Rules for Insurers’ Annual Limits
July 6, 2011 – On June 17, 2011, CMS issued guidance to allow limited benefit, or mini-med plans, to apply for or renew a temporary waiver from annual limit restrictions through 2013. In 2014, annual limits for new health plans will be banned as “high-quality, affordable, and comprehensive health insurance plans are made available [...]Tags: Healthcare Reform
GEMS and the Partial ICD-9 Code Freeze
July 6, 2011 – CMS and the Centers for Disease Control and Prevention (CDC), with collaboration from other organizations, created the national version of the General Equivalence Mappings (GEMS) to ensure that consistency in national data is maintained and to assist with the conversion from ICD-9-CM codes to the new upcoming ICD-10-CM codes. GEMS [...]Tags: ICD-10
HIT Policy Committee Votes to Recommend Delay of Stage II Meaningful Use
July 6, 2011 – In January 2011, a draft of Stage 2 meaningful use criteria was released for public comment which concluded on February 25. The recommended Stage 2 objectives are heightened versions of Stage 1 measures and increases the number of capabilities that an EHR must have in order for providers to be [...]Tags: EHR, Meaningful Use
SGR Update (July 2011)
July 6, 2011 – On June 28, Senators Joseph Lieberman (I-Conn) and Tom Coburn, MD (R-Okla) released a Medicare proposal offering a three-year “fix” for the SGR formula that determines physician reimbursement. The Senators claim their bill will save Medicare $600 billion over 10 years by shifting costs to Medicare beneficiaries and increasing the Medicare [...]Tags: SGR and Medicare Fee Schedule
CMS Proposes 2012 Physician Fee Schedule
July 6, 2011 – On July 1, 2011, CMS issued a proposed rule that would update payment policies and rates for physicians and nonphysician practitioners for services provided in calendar year 2012. Some of the highlights of the proposed rule are as follows: Unless Congress steps in, the Medicare payments for 2012 would be [...]Tags: SGR and Medicare Fee Schedule
PQRS & eRx Reminders
July 6, 2011 – PQRS Claims – 6 Month Participation If you have not yet submitted claims for the 2011 PQRS program, you may begin to participate in the six (6) month PQRS reporting period of service dates July 1 – December 31, 2011. All claims for these service dates must be submitted to Medicare by [...]Tags: eRx Incentive Program, PQRS Incentive Program
IRS Delays Enforcement of 5% Withhold Rule
June 16, 2011 – The IRS has suspended enforcement of the 3% withhold rule until January 1, 2013. This rule was originally enacted as part of the Tax Increase Prevention and Reconciliation Act of 2005 (TIPRA) requiring all federal agencies withhold an amount equivalent to 3% of federal payments made to individuals or corporations [...]Tags: CMS Updates
CMS Provides First Medicare EHR Incentive Payments Totaling $75 million
June 16, 2011 – The first payments from the Medicare EHR incentive program were issued on May 19 in the amount of $75 million. In addition to these payments, fifteen (15) states have initiated their Medicaid EHR incentive programs since January 2011. As of June 3, over $83 million in incentive payments have been made [...]Tags: EHR, Meaningful Use
HHS Issues Rule on Major Insurance Premium Hikes
June 16, 2011 – In May, HHS (Department of Health & Human Services) released a final rule that will allow states to scrutinize insurance companies if they propose excessive increases in insurance premiums. The rule would give states the authority to issue a review of any insurer that raises premiums for small-group or [...]Tags: Healthcare Reform
CMS Pushes Back Deadlines for new Pioneer ACO Model
June 16, 2011 – CMS has announced an extension of the deadlines for the letters of intent and applications for the Pioneer ACO Model, which was released last month. Feedback from the provider community stating more time was needed to complete both the letters and the applications initiated CMS to delay the deadlines as [...]Tags: Healthcare Reform
ACO Development Learning Sessions
June 1, 2011 – Providers and executive leadership teams from existing or emerging ACO entities interested in learning more about the steps necessary to become an ACO can attend an upcoming series of Accelerated Development Learning Sessions. Four sessions will be offered and are for free. Each session will include a focused curriculum on [...]Tags: Healthcare Reform
CMS Announces Two New ACO Initiatives
June 1, 2011 – On May 17, 2011, CMS’ Innovation Center released the following three (3) new initiatives under the Shared Savings Program designed to help physicians, hospitals and other health care providers to become accountable care organizations (ACOs). Pioneer ACO Model This model is designed for health care organizations and providers that are already [...]Tags: Healthcare Reform
CMS Modifies E-Prescribing Payment Adjustment Rule
June 1, 2011 – With the deadline right around the corner for the submission of 10 electronic prescriptions to avoid the 2012 payment adjustment penalty, CMS issued a proposed rule last Thursday to increase the number of hardship exemptions from this eRx measure. To avoid the 2012 payment adjustment penalty, the rule originally required participation [...]Tags: eRx Incentive Program
CMS Allows Third Parties to Register EPs for EHR Meaningful Use
June 1, 2011 – CMS has recently implemented functionality that allows an eligible provider (EP) to designate a third party to register and attest on his or her behalf for the EHR Meaningful Use program. To do so, users working on behalf of an EP must have an Identity and Access Management System (I&A) [...]Tags: EHR, Meaningful Use
Home Health Rule – Documentation of Face-to-Face Encounters
May 19, 2011 – The rule requiring physicians and others to document face-to-face encounters when ordering home health services for Medicare patients went into effect on April 1, 2011. Under the rule, a physician or authorized non-physician practitioner whose patient needs home health services must document a face-to-face visit with the patient within 90 [...]Tags: Coding, Documentation
CMS Announces New Federal Health Care Programs
The federal government has recently released the following two new health care programs: Partnership for Patients Value-Based Purchasing Partnership for Patients: Better Care, Lower Costs The Partnership for Patients is a new public-private partnership designed to help improve the quality, safety, and affordability of health care for all Americans. The program brings together [...]Tags: Healthcare Reform
CMS Releases the Medicare PQRS Experience Report for 2009
May 12, 2011 – In April,CMS released the PQRS and eRx data for 2009. The report “summarizes the experience of eligible professionals (EPS) who participated in PQRS in 2009, as well as trends in the program over time, including early results from the 2010 program year.” Here are some of their statistics: The PQRS [...]Tags: PQRS Incentive Program
SGR Update
May 12, 2011 – It appears Congress is attempting to not wait until the last minute to discuss the SGR payment formula this year. The House Energy and Commerce Committee (CEC) sent a letter to 51 medical organizations on March 28 for ideas on how to reform Medicare’s payment formula, stating they want to [...]Tags: SGR and Medicare Fee Schedule
RACs recovered $162 million in overpayments in 2011
May 12, 2011 – CMS released data in April on the amounts of overpayments and underpayments collected by Recovery Audit Contractors (RACs) in the first quarter of 2011. The total overpayments collected were $162 million while the underpayments totaling $22.6 million were returned to providers during the same time period, resulting in a net [...]Tags: RAC Audits
Comments Due on ACO Proposed Ruling
May 12, 2011 – You have until June 6, 2011, to submit your comments to CMS showing your support of or concerns about the Accountable Care Organization (ACO) proposed rule created under the Accountable Care Act’s Shared Savings Program issued on March 31, 2011. The program creates incentives for health care providers to work together [...]Tags: Healthcare Reform
50 days left to avoid e-prescribing penalties
May 12, 2011 – All eligible professionals (EPs) must successfully e-prescribe for Medicare patients ten (10) times for service dates between January 1, 2011 and June 30, 2011, by submitting code G8553 via claims-based reporting, to avoid the one percent (1%) payment adjustment in 2012. Even if the EP attests to being a meaningful user of their [...]Tags: eRx Incentive Program
New Provider Enrollment Provisions
April 20, 2011 - As designated under the Affordable Care Act, new provider enrollment provisions, designed to continue CMS’ efforts to reduce fraud, waste, and abuse, were published in the final rule with comment entitled, “Medicare, Medicaid and the Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans [...]Tags: Provider Enrollment
CMS Releases ACO & Shared Savings Regulations
April 20, 2011 – On March, 31, 2011, CMS passed a proposed rule (Section 3022 of the Affordable Care Act) to establish the CMS definitions of an Accountable Care Organization (ACO) and the Shared Savings Program. Comments on this proposed rule will be accepted until June 6, 2011, with the final rule adopted shortly [...]Tags: Healthcare Reform
EHR Meaningful Use Attestation
March 8, 2011 – Eligible professionals (EPs) participating in the Medicare EHR Incentive Program may begin the attestation process on April 18, 2011. EPs must first complete the 90 day-reporting requirements for Stage 1 of the program before attestation. For more information on how to register and attest, please click below. EHR Registration and AttestationTags: EHR, Meaningful Use
Congress Discusses Medicare Fraud
March 8, 2011 – Three congressional committees held hearings to discuss health care fraud last Wednesday. In a report prepared for the House Ways and Means Committee Subcommittee on Oversight, “nearly 10% of all Medicare payments are fraudulent, causing the federal government to lose $48 billion on phony claims and other improper payments in 2010.” [...]Tags: Fraud and Abuse, Healthcare Reform
Be Careful Who You Hire
The Office of the Inspector General (OIG) urges health care providers and entities to check the OIG List of Excluded Individuals/Entities on the OIG website prior to hiring or contracting with individuals or entities. They also advise health care providers to periodically check the web site to determine the participation/exclusion status of current employees and contractors. [...]Tags: Fraud and Abuse
2012 Proposed Federal Budget Includes Extending the SGR cut for 2 years
February 16, 2011 – The recent announcement by President Obama of the $3.7 trillion budget for fiscal year 2012 includes postponing the scheduled 25% SGR cut for two years, continuing the current payment levels until September 2013. The two-year payment fix would cost $54 billion. The President states that payment to postpone the cut would come from several sources including: Provisions [...]Tags: SGR and Medicare Fee Schedule
New Information for Services Provided in the patient’s HOME
2011 CN2 – January 11, 2011 Effective for claims processed as of 1/1/2011, CMS (Medicare) requires that the HOME place of service (POS) must contain the address of the service. The zip code of the patient’s (or family’s) home, where services were rendered, will determine the correct payment locality. This information must be provided for any other [...]Tags: Medical Billing
New – The Center for Medicare and Medicaid Innovation
2011 CN2 – January 11, 2011 The Affordable Care Act also required CMS to create the “Center for Medicare and Medicaid Innovation” also known as the Innovation Center, which will “explore innovations in healthcare delivery and payment” designed to: enhance the quality of care for Medicare and Medicaid beneficiaries, improve the health of the population, and [...]Tags: Healthcare Reform
NEW – CMS Provider Directory & Physician Compare Website – January 2011
On December 30, 2010, CMS enhanced their Physician Directory with new information about physicians and non-physician providers with a new tool called Physician Compare. This new site was developed in response to requirements designated by the Affordable Care Act of 2010. This site is designed to be consumer-friendly and help patients locate health professionals in their communities. Current [...]Tags: Healthcare Reform
2011 MPFS Conversion Factor has been Established
The 2011 conversion factor (CF) has been established at $33.9764, an 8% decrease from the 2010 CF of $36.8729. Although the physician fee schedule update is 0%, the physician fee schedule final rule resulted in a number of changes in both the practice expense component of the RVU as well as adjustments to the calculation of [...]Tags: SGR and Medicare Fee Schedule
2011 New England Insurance Company Updates
This page contains updates from insurance carriers who operate in New England. The affected carriers and topics are lised first followed by the details. CT – Community Health Network of CT Radiology Notification Program CT & RI – AmeriChoice Name Change MA – Blue Shield Medicare Product Benefit Change Requirements for Cardiac CT Studies MA – Fallon [...]Tags: Medical Billing
2011 Medical Billing Updates
The Affordable Care Act (ACT) of 2010 not only affected physician payment policies but will be influential in the future delivery of healthcare. As a result of the ACT, CMS has established 2 new websites dedicated to these changes: the Physician Directory & Compare and the Center forInnovation. If you have not read extensively about the direction of healthcare under [...]Tags: Medical Billing
SGR Update: 2012 Budget Extends Current Rates for Two Years
February 16, 2012 The Fiscal 2012 budget that President Obama submitted to Congress on Monday proposes a 2 year SGR fix, for calendar years 2012 and 2013. The budget then assumes that Congress will find a permanent fix for the SGR problem beginning in 2014. According to Administration officials, the budget would trim the deficit [...]Tags: SGR and Medicare Fee Schedule
2011 New England Insurance Company Updates
This page contains updates from insurance carriers who operate in New England. The affected carriers and topics are lised first followed by the details. CT – Community Health Network of CT Radiology Notification Program CT & RI – AmeriChoice Name Change MA – Blue Shield Medicare Product Benefit Change Requirements for Cardiac CT Studies MA [...]Tags: Medical Billing
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