Tagged with Provider Contracting and Enrollment

HHS Releases Final Interoperability Rules

CMS and the Department of Health & Human Services (HHS)’ Office of the National Coordinator for Health Information Technology have released two interoperability rules. The new rules aim to make it easier for patients to access and share their information and aim to end information blocking by requiring public and private entities to securely share health information with patients and penalize those who fail to do so.

$8.3B Coronavirus Funding Bill Approved

During the first week in May, the U. S. House and Senate approved an $8.3 billion funding bill to support ongoing efforts to combat COVID-19 (Coronavirus). On March 6, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074) was finalized by the president

HHS Releases Final Recommendations on Reducing Clinical Burden

The U.S. Department of Health & Human Services (HHS) released the final version of its Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs. The strategy aims to reduce clinician burden through incremental changes that will push of electronic health record systems toward interoperability while easing regulatory burden.

Ohio Revises Definition of Ambulatory Surgical Facilities

Ohio has released the recently revised definition of an Ambulatory Surgical Facility (ASF), as part of the new 2020/2021 general operating budget legislation. The change expanded the ASF definition, which may require some previously unlicensed facilities to obtain licensure.

Anthem Outpatient Facility Edit Implementation

Effective April 26, Anthem Blue Cross Blue Shield (Anthem) will make changes to its outpatient facility edits for revenue codes, CPT® codes, HCPCS and modifiers. These edits will include changes to appropriate use of various code combinations, such as, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier.

Humana Claims Payment and Medical Coverage Policy Updates

Humana has published new and recently updated claim payment policies, including new policies for inpatient readmission review, modifiers CO and CQ, as well as revisions to the insurer’s chronic care management and principal care management and telehealth services policies.

Anthem CT Posts Advanced Imaging Clinical Appropriateness Guideline Updates

Anthem Blue Cross and Blue Shield (Anthem) of Connecticut (CT) released certain updates to its Vascular Imaging Clinical Appropriateness Guidelines which includes new and updated language for indication of asymptomatic enlargement by imaging and clarifying surveillance intervals for stable aneurysms.

Anthem Ohio Clinical Laboratory Improvements Amendments

Beginning May 1, claims that are submitted to Anthem Blue Cross and Blue Shield (Anthem) of Ohio for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations will require additional information to be considered for payment.

CMS Announces Plans to Change Prior Authorization Rules

CMS Administrator, Seema Verma, on February 11, announced the agency’s intent to reform prior authorization regulations later this year. According to Verma, the changes “will reduce administrative waste, increase patient safety and free physicians to spend time caring for their patients.”

Aetna HCPCS Code Updates to Specific Drug Contract Service Groupings

Effective March 1, Aetna will implement code updates under which individual service codes will be assigned within contract service groupings. Changes to an individual provider’s compensation will depend on the presence or absence of specific service groupings within the contract.

House Ways and Means Releases Surprise Billing Proposal

On February 7, the U.S. House Ways and Means Committee released its proposed Consumer Protections Against Surprise Medical Bills Act of 2020. If passed, the proposal would ban balance billing for emergency care, care provided by a nonparticipating provider in a participating facility, and in other circumstances of misinformation. The proposal also includes provisions to establish a dispute resolution process for out-of-network reimbursement disagreements.

CMS Releases 2021 MA and Part D Advance Notice Part II

On February 5, CMS released Part II of the Calendar Year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. In the CY 2021 Advance Notice, the agency is proposing updates and changes to the methodologies used to pay MA plans, Programs of All-Inclusive Care for the Elderly (PACE) organizations, and Part D sponsors.

CMS Publishes FY 2022 SNF APU Overview Table

CMS, on January 30, published the Fiscal Year (FY) 2022 Skilled Nursing Facility (SNF) Annual Payment Update (APU) table, indicating the data elements the agency will use for FY 2022 SNF Quality Reporting Program APU determinations.