Tag Archives: Medicare

2019 Proposed Medicare Fee Schedule

The 2019 proposed Medicare Fee Schedule was published on July 27, 2018 by CMS at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf. Pages 61 through 91 of the Executive Summary are devoted to: Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services.  Click here to read: Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services. This subsection is devoted to explaining both … Continue Reading

Medicare Telehealth Services

Just as a point of providing information, please note that CMS has revised its Medicare Learning Network (MLN) booklet for telehealth services.  The February 2018 edition is included in this link.  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf The 2019 proposed Medicare Physician Fee Schedule Rule also seeks comments on proposed expansion of telehealth services.  That will be the subject of … Continue Reading

Telehealth Reaches Tipping Point – Now Included in OIG Audit Plan

Telehealth has apparently reached the tipping point in its significance to the Medicare budget, because OIG has now announced that it will “review Medicare claims for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.” The expected issue date of the … Continue Reading

West Virginia Doctor Secures Temporary Restraining Order Against Medicare Exclusion

In Robie v. Price, Dr. Robie successfully obtained a temporary restraining order prohibiting CMS from terminating his Medicare billing privileges prior to the exhaustion of his administrative remedies by the U.S. District Court for the Sothern District of West Virginia. As most realize, exhaustion of administrative remedies is usually a prerequisite to further litigation for … Continue Reading

2017 Medicare Telehealth Changes

The 2017 Medicare Physician Fee Schedule finalizes the CMS changes for Telehealth reimbursement and coverage for 2017.  The CMS fee schedule document also provides a comprehensive explanation of Medicare Telehealth reimbursement and coverage.  I have excerpted those 35 pages and linked them as a PDF to this post: Medicare Telehealth Services. The essential takeaways are as … Continue Reading

Progress on Medicare Payment Reform

HHS is gearing up to design and implement a revised Medicare payment system.  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has designated a merit based incentive payment system (MIPS) as a goal.  CMS is tasked to design a value based payment system based upon quality, resource use, clinical practice improvement, and meaningful … Continue Reading

SGR Fix Already Revised and Hospital Outpatient Department $$ Reduced

The ink was barely dry on the Medicare Physician Sustainable Growth Rate (SGR) fix, and it has already been changed. One component of the SGR fix, which was just passed in April of this year, was freezing Medicare physician payments from 2019 through 2025, and then allowing a .75% increase for physicians participating in alternative … Continue Reading

IRS Levy Against Medicare Payments Increases to 100% Effective October 16, 2015

The Internal Revenue Code was amended in April 2015 as part of the Medicare Access and CHIP Reauthorization Act of 2015 to increase allowable IRS levies against federal payments, such as Medicare receivables, from 30% to 100% effective October 16, 2015. CMS has issued MLM Matters –  MLM number MM9285, to explain these changes.  … Continue Reading

CMS Limits Scope of Review for MACs

CMS issued a special edition MLN Matters meant to be effective August 1, 2015.  The guidance reflects CMS instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations of certain claims. CMS acknowledges its concern that MACs and QICs were using their discretion to conduct … Continue Reading

Telehealth News

There are two interesting items in telehealth news. Iowa Supreme Court Rejects Ban on Telemedicine Abortions An Iowa Board of Medicine rule requires the presence of a physician when abortion inducing drugs are provided.  Planned Parenthood sued claiming the requirement of physician presence was unconstitutional on the basis that it discriminated against women, due to … Continue Reading

Colorado Approves Direct Medicare Payment to CRNA’s

Medicare Regulations allows CRNA’s to administer anesthesia without physician supervision if the state governor opts out of the regular physician supervision requirement. Governor Ritter of Colorado opted out in 2010, and his action was challenged by the Colorado Medical Society and the Colorado Society of Anesthesiologists.  That challenge was dismissed by Colorado trial courts, which … Continue Reading

CMS Proposes Rules to Improve Accountable Care Organizations (ACOs)

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule intended to make ACOs and Medicare Shared Savings Plans more practical and attractive to potential providers. The proposed rule was released on December 1, 2014, along with a CMS Fact Sheet. Longer Lead Time to Develop In order to provide more development time, … Continue Reading

Global Surgery and 2015 Medicare Physician Fee Schedule

On July 21, 2014, I posted the proposed Medicare Physician Fee Schedule, and described the intent by CMS to eliminate global surgery. On November 13, 2014, CMS issued the final 2015 Medicare Physician Fee Schedule, and CMS incorporated the changes regarding global surgery. Global Surgery There are three primary categories of global surgery packages that … Continue Reading

Face-to-Face Medicare Reimbursement Requirements for Home Health Certification

CMS has announced its concern regarding the level of compliance for documenting the face-to-face elements necessary for home health care certification. Attached is an educational piece published by Novitas Solutions on its Part B website. It lists the qualification criteria for home health benefits: Be confined to a home; Under the care of a physician; … Continue Reading

OIG Report: Questionable Billing for Medicare Part B Clinical Laboratory Services

Perhaps not coincidentally, immediately following the release of the Questionable Laboratory Payments Special Fraud Alert by the OIG, posted yesterday on the Med Law Blog, the OIG has followed up with Audit Report OIG – 03-11-00730: Questionable Billing for Medicare Part B Clinical Laboratory Services. Below are two quoted paragraphs from the executive summary stating … Continue Reading

Practical considerations to protect against being ‘out of network’

Practical considerations to protect against being ‘out of network’ The disengagement of Highmark and UPMC is looming on the horizon; most of the hospital participation agreements between these two competing healthcare systems end on December 31, 2014.  There are some hospital agreements that continue, such as those at Children’s and Magee, but the focus of … Continue Reading

2014 OIG Work Plan: Impact of Provider-Based Status on Medicare Billing

The 2014 OIG Work Plan includes the following:  Policies and Practices. We will determine the impact of subordinate facilities in hospitals billing Medicare as being hospital based (provider based) and the extent to which such facilities meet CMS’s criteria. Context—Provider-based status allows a subordinate facility to bill as part of the main provider. Provider-based status … Continue Reading

AMA Reports; Supercommittee Stalemate Leaves SGR 27.5 Physician Fee Schedule Decrease Intact

Supercommittee failure leaves 27 percent Medicare payment cut in place With the Joint Select Committee on Deficit Reduction failing to reach agreement on a deficit-reduction proposal, physicians still face a 27 percent cut in Medicare physician payments scheduled to take effect Jan. 1. Congress has missed an opportunity to address the nation’s fiscal problems, stabilize … Continue Reading

CMS Releases 2012 Medicare Physician Fee Schedule With 27.4% Decrease

CMS ANNOUNCES POLICY, PAYMENT RATE CHANGES FOR THE PHYSICIAN FEE SCHEDULE IN 2012 The Centers for Medicare & Medicaid Services (CMS) today issued a final rule with comment period that updates payment policies and rates for physicians and nonphysician practitioners (NPPs) for services paid under the Medicare Physician Fee Schedule (MPFS) in calendar year (CY) … Continue Reading

Final CMS Accountable Care Organization Regulations Provide ACOs more Flexibility

CMS has finally released the final rule for the Medicare Shared Savings Program, which is the program that establishes the rules for Accountable Care Organizations (ACOs). The initial industry objections to the ACO concept and the proposed regulations was that it was so complicated, so limited and potentially so expensive that it would be impossible, … Continue Reading
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