Changes to Medicare Part D Coverage Determinations and Appeals Process (This information applies to Blue Advantages PPO) Blue Care Plus HMO SNP is excluded unless stated otherwise. The Medicare Part D coverage determination and appeal process for BlueAdvantage (PPO) and BlueCare PlusSMmembers is currently managed by Express Scripts, Inc. (ESI). Beginning July 2, 2018, BlueCross will […]
Discontinued Printed Commercial Prior Authorization Letters`BCBS`
Starting this month, Commercial prior authorization approval letters will be sent by fax. We will no longer mail approval letters. This will speed up the approval process and prevent misrouted letters. Prior authorization requests may be made by fax or phone, and you can get immediate approvals on some authorizations by logging in to the Availity Provider […]
Global Surgical Package Billing and Guidelines`Blue Cross Alert` June 2018
BlueCross updated its claims payment process in August 2017 to include a more careful analysis during the pre- payment phase of claims editing. The goal is to deliver payments to providers with more accuracy, reducing the need for recovering payments that exceed claims liability for all lines of business. Periodically, we publish reminders to help […]
Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
Provider Compliance As reported in the Medicare Quarterly Compliance Newsletter (October 2017), the Comprehensive Error Rate Testing (CERT) review contractor conducted a study of claims for arthroscopic rotator cuff repairs billed with HCPCS code 29827 submitted from January through March 2016. Most improper payments were due to insufficient documentation. Avoid documentation errors and payment recoveries: […]

New Medicare Card Mailing Update-Wave 3 Begins, Wave 1 Ends
We started mailing new Medicare cards to people with Medicare who live in Wave 3 states: Arkansas, Illinois, Indiana, Iowa, Kansas, Minnesota, Nebraska, North Dakota, Oklahoma, South Dakota and Wisconsin. We continue to mail new cards to people who live in Wave 2 states and territories (Alaska, American Samoa, California, Guam, Hawaii, Northern Mariana Islands, […]

Texas Cancer Center Violated the HIPAA and Security Rules
Judge rules in favor of OCR and requires a Texas cancer center to pay $4.3 million in penalties for HIPAA violations A U.S. Department of Health and Human Services Administrative Law Judge (ALJ) has ruled that The University of Texas MD Anderson Cancer Center (MD Anderson) violated the Health Insurance Portability and Accountability Act of […]

What You Should Know About OCR HIPAA Privacy Rule Guidance Materials
Be aware of misleading marketing claims The Office for Civil Rights (OCR) has made available on this web site guidance materials on the Privacy Rule as a service to the public to help covered entities comply with the rule and to help consumers know how they are protected by the Privacy Rule. All items on […]

Double-Check Appeals’ Requests and Jurisdiction, MAC Urges
CMS paperwork can be confusing, but one Medicare Administrative Contractor is reporting an uptick in problems with appeals processing. “CGS [Medicare] has noticed an influx in receiving misrouted appeal requests from providers,” said the MAC in a Nov. 21, 2017 notice. “In some cases, providers are using the correct contractor appeal form; however, mailing to […]

HHS OIG Report
OIG posts a report, corporate integrity agreements, advisory opinion and enforcement actions. As always, you can use the links provided to go directly to the new material. Report Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2018 (OEI-05-18-00240) This report fulfills for 2018 the annual reporting mandate from the Patient Protection and […]

New Medicare Cards May have QR Codes
New Medicare cards may have a square code, also referred to as a QR code (a type of machine-readable code). The QR codes on Medicare cards allow the contractor who prints the cards to ensure the right card goes to the right person with Medicare or Railroad Retirement Board (RRB) benefits. Providers cannot use it for […]

United Healthcare Group’s Service Operations Virtual Career Fair June 26th & 27th
What inspires your life can transform your career. Access Virtual Environment June 26 & 27 | Recruiter Chat: 8:00-4:00 CT | Environment Open 24 Hours Thank you for registering to join UnitedHealth Group’s Service Operations Virtual Career Fair. During the event, you’ll learn about our diverse workforce, company culture and the many career path options […]

2018 Bipartisan Budget Act Revises Stark Law Regulations-Part II
The Bipartisan Budget Act of 2018 (the “Act”), signed into law on February 9, 2018, contains an amendment that should cause physicians and healthcare providers to take note. Section 50404 of the Act, titled “Modernizing the Application of the Stark Rule under Medicare,” codifies recent Centers for Medicare and Medicaid Services (“CMS”) regulations and corresponding […]

2018 Bipartisan Budget Act: Greater Access, Innovation, and Technology in the Administration of Medicare Advantage Plans-Part I
Prior to adjourning for spring recess, Congress passed and the President signed into law on March 23, 2018, omnibus appropriations legislation that funds the government for the remainder of the fiscal year – through September 30. As part of the earlier negotiations to reach the budget deal, Congress passed and the President signed into […]
New Medicare Card: MBI Look-up Tool Available through your MAC
All Medicare Administrative Contractor (MAC) secure portal Medicare Beneficiary Identifier (MBI) look-up tools are ready for use. If you don’t already have access, sign up for your MAC’s portal to use the tool. Submit four data elements about your patient through the tool, and we will return the MBI if we have already mailed the […]
Isn’t it time you beat the denial game?
Our Orthopaedic Health Team will address the significant denials challenge with effective, evidence-based guidance and strategies that cover the range of reasons for denied claims: Medical Necessity Medically Unlikely Edit (MUE) No Authorization Partial Authorization Insufficient Documentation Different Procedure Billed Than the Pre-authorized Procedure Outdated CPT® code Obsolete/Deleted Diagnosis Codes Modifier Error RAC (Recovery Act […]
How Email And Texting Should be handled, And The Price of Getting It Wrong
Are you clear on how e-mail and texting patients should be handled? Do you know how the HIPAA enforcement process could impact your practice and business associates (BAs)? Do you have an exit strategy for BA breaches? Are you aware of what activities invite an audit and how to eliminate your risk? With ramped up scrutiny and greater risk exposure, complying with HIPAA regulations has […]
False Claims Act` Healthcare Anti-Kickbacks
Fort Myers Pain Management Physician Pleads Guilty To Healthcare Offenses And Agrees To $2.8 Million Civil Settlement With The United States` Fort Myers, FL – Dr. Michael Frey, M.D. (46, Fort Myers) has pleaded guilty to two counts of conspiracy to receive healthcare kickbacks. He faces a maximum penalty of five years in federal prison […]
Health Care Fraud–Non`Compliance with Medicaid
Operators Of A Mental Health Provider Indicted On Health Care Fraud And Tax Evasion Charges.. A federal grand jury sitting in Greensboro, North Carolina returned an indictment, which was unsealed today, charging the operators of a mental health provider with multiple crimes related to the submission of false claims to Medicaid and tax evasion, announced […]
Hip-replacement Technique gets patients back on their feet sooner
Same-day discharge surgery is still a novel approach, but it’s increasingly used by doctors in Canada Sheryl Ubelacker · The Canadian Press · Posted: May 27, 2018 11:38 AM ET | Last Updated: May 27 Physiotherapist Ellen Newbold, right, helps Tim Heenan walk as he prepares for his release following day surgery for a hip […]
New Medicare Card Project-Card Mailing Update
CMS has started mailing new Medicare cards to people with Medicare who live in Wave 2 states and territories: Alaska, American Samoa, California, Guam, Hawaii, Northern Mariana Islands, and Oregon. We continue to mail new cards to people who live in Wave 1 states, as well as nationwide to people who are new to Medicare. […]