Medicare Part D Coverage Determinations and Appeal Processes Update Beginning July 2, 2018

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 […]

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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 […]

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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: […]

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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, […]

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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 […]

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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 […]

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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 […]

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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 […]

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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 […]

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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 […]

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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 […]

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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. […]

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