Medical Billing Industry News
Welcome to Medical Billing Industry News from AHS. As we all know, our industry has many moving parts and it’s hard to keep up. Here we highlight some of the items of particular importance for physician billing, practice management and proper reimbursement for physicians, ASC’s and other healthcare providers.
Most of the articles here have “tags” that represent the key topics. You can click on any tag and immediately get all of the articles on that topic.
We’ve recently published the AHS PQRS Manual for 2012: you can find it here.
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
