Tagged with Provider Contracting and Enrollment

HHS to Cap HIPAA Fines Based on ‘Culpability’

The Department of Health and Human Services (HHS) has published it’s Notice of Enforcement Discretion Regarding HIPAA Civil Monetary Penalties, updating the maximum amount it will penalize providers, health plans and business associates for HIPAA violations.

CMS Releases 2020 Medicare Advantage and Part D Rates

On April 1, CMS released its finalized payment and policy changes for Medicare Advantage (MA) and Medicare Part D plans for the 2020 coverage year. CMS states the final updates will continue to maximize competition among Medicare Advantage and Part D plans, as well as include important actions to address the nation’s opioid crisis.

New Jersey Will Transition to a State-Based Exchange

On March 22, the governor of New Jersey has announced that the state will transition from the federally operated Healthcare.gov exchange platform to a state-based exchange by the 2021 plan year. According to state officials, the change will give the state more control over its health insurance market.

New Hampshire Senate Passes Medicaid Telehealth Bill

The New Hampshire Senate has passed a bill expanding Medicaid coverage for telehealth services. The bill, if finalized, would allow a patient to receive primary care in addition to specialty care via telehealth and enables Medicaid to cover far more connected care services than previously.

Federal Judge Rules ACA is Unconstitutional

A federal judge in Texas has ruled that the entire Affordable Care Act (ACA) is unconstitutional on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it.

New York – Anthem Reimbursement Policy Updates

Anthem has posted several reimbursement policy updates, including updates to its Rule of Eight” Reporting Guidelines, system updates for 2019, and updates to policy for Modifier 69.

E/M Coding Changes Delayed Until 2021

In the recently published final version of the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP), CMS modifies and delays certain proposed changes to evaluation and management (E/M) codes.

CMS Announces Short-Term IMD Exclusion Waivers for Mental Illness

CMS announced on November 13, a new opportunity for states to seek short-term IMD exclusion waivers, which would allow Medicaid to pay for inpatient mental health services for adults with serious mental illness and children with serious emotional disturbance.

Anthem – Enhanced Automated Claim Edits

Anthem is updating its editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT®, HCPCS Level II, and ICD-10. Anthem states the enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.