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

June 30, 2018June 30, 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 […]

Discontinued Printed Commercial Prior Authorization Letters`BCBS`

June 30, 2018

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

June 30, 2018June 30, 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

June 30, 2018

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

June 26, 2018June 26, 2018

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

June 26, 2018June 26, 2018

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

June 26, 2018June 26, 2018

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

June 26, 2018June 26, 2018

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

June 26, 2018June 26, 2018

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

June 25, 2018June 25, 2018

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

June 21, 2018June 21, 2018

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

June 13, 2018June 13, 2018

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

June 13, 2018June 13, 2018

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

June 12, 2018June 12, 2018

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?

June 12, 2018

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

June 9, 2018

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

June 5, 2018June 9, 2018

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

June 5, 2018June 9, 2018

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

June 5, 2018

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

June 1, 2018

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. […]

With CMS resuming medical necessity audits through QIOs and RACs and commercial payers continuing to issue denials, downgrades, and pended decisions, medical practices are struggling to counter the toll on their financial health. Many organizations face a daunting backlog of denials, some of which represent hundreds of thousands of dollars at risk. Recovering your lost revenue from denials can help you preserve profitability in the face of limited operating margin. Yet, managing appeals is time consuming. Tracking claim judgements, researching reasons for denials, collecting necessary documentation, and writing and submitting appeals is labor-intensive, especially when your staff is under-trained. Learn how to avoid denials, prioritize those denials likely to win an appeal, and establish ongoing services to prevent backlogs from emerging in the future working with our team!

Wednesday June 6th 1:30pm-3pm ET

CMS experts discuss the qualified Medicare Beneficiary QMB Billing requirements and their implications. Find out about the July 2018 re-launch of changes to the remittance advice and November 2017 changes to the HIPAA Eligibility Transaction system (HETS) to identify the QMB status of your patients and exemption from cost`sharing. Also learn the key steps to promotion compliance.

Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays. Visit the QMB Program webpage for more information.

Tuesday, June 12 from 1 to 2 pm ET

Learn information about the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS). CMS will:

Provide a brief overview of MIPS requirements in 2018
Discuss the renaming of Advancing Care Information to Promoting Interoperability
Explain the Promoting Interoperability performance category requirements for 2018
Discuss scoring for the Promoting Interoperability performance category

Friday, July 13 from 8 am to 12:30 pm

CMS Central Office, Baltimore, MD or via phone/webinar

Join us for a focus group meeting on Medicare Fee-for-Service compliance topics. This is a chance for us to get together and talk about medical review, targeted probe and educate, the Recovery Audit Contractors and more. CMS is most interested in hearing from you about what we can do to better communicate, improve our processes, and eliminate unnecessary requirements. We want to ensure claims are paid appropriately and preserve the Medicare Trust Fund for future generations. We also want to make it easier for you to submit claims accurately and manage the audit process if you’re audited.

Target Audience: Physicians, non-physician practitioners, billing specialists, suppliers, and associations

The Work Plan

The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG’s Office of Audit Services and Office of Evaluation and Inspections. Projects listed in the Work Plan span the Department and include the Centers for Medicare & Medicaid Services (CMS), public health agencies such as the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH), and human resources agencies such as Administration for Children and Families (ACF) and the Administration on Community Living (ACL). OIG also plans work related to issues that cut across departmental programs, including State and local governments’ use of Federal funds, as well as the functional areas of the Office of the Secretary of Health & Human Services (HHS). Some Work Plan items reflect work that is statutorily required.

How and Where We Operate

OIG operates by providing independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS. OIG’s program integrity and oversight activities adhere to professional standards established by the Government Accountability Office (GAO), Department of Justice (DOJ), and the Inspector General community. OIG carries out its mission to protect the integrity of HHS programs and the health and welfare of the people served by those programs through a nationwide network of audits, investigations, and evaluations, as well as outreach, compliance, and educational activities.

How We Plan Our Work

We assess relative risks in HHS programs and operations to identify those areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated. Audits and evaluations may be cancelled based on OIG staff availability, changes in the environment, legislation that substantially affects the issue, or similar recent studies that provided definitive results. Reports are cancelled only after senior staff have reviewed and approved the cancellation. It you have additional questions please contact OIG Communications Office at (202) 619-0088. In evaluating potential projects to undertake, we consider a number of factors, including:

mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directives;
requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget;
top management and performance challenges facing HHS;
work performed by other oversight organizations (e.g., GAO);
management’s actions to implement OIG recommendations from previous reviews; and
potential for positive impact.

In addition to working on projects that often result in audits, reviews, and reports, OIG’s work portfolio includes a number of legal and investigative activities. Click on the links below for more information about OIG’s legal and investigative efforts:

Investigating Fraud, Waste and Abuse
Facilitating Compliance in the Health Care Industry
Excluding Bad Actors from Participation in Federal Health Care Programs

Updates to the Work Plan

OIG updates this dynamic, web-based Work Plan monthly to ensure that it more closely aligns with the work planning process. The monthly update includes the addition of newly initiated Work Plan items, which can be found on the Recently Added Items page. Also, completed Work Plan items will be removed. Recently published reports can be found on OIG’s What’s New page. This web-based Work Plan will evolve as OIG continues to pursue complete, accurate, and timely public updates regarding our planned, ongoing, and published work.

If you have questions about our Work Plan, please contact us at public.affairs@oig.hhs.gov.

https://oig.federalreserve.gov/reports/oig-work-plan.pdf

On April 5, 2017, Governor Bill Haslam signed
into law the Provider Stability Act (PSA) − a
new Tennessee mandate intended to increase transparency and accountability between Tennessee health plans and contracted health care providers. This law, which will take effect Jan. 1, 2019, will require Tennessee health plans to:

Notify health care providers of any material change made at the sole discretion of the insurance entity to a previously released provider manual or a reimbursement rule and policy at least 60 days before the effective date of the change
Notify health care providers of any change to a provider’s fee schedule and the effective date of the change at least 90 days prior to the effective date of the change
Limit fee schedule changes to once in a 12-month period
Send all Provider Stability Act notices and disclosures to a dedicated email address supplied by the provider
The PSA only applies to contracted Commercial providers in Tennessee.

Many companies are now utilizing high-deductible health plans for their health insurance coverage. The Society for Human Resource Management states, “…46 percent of employers will take steps to reduce cost growth in 2018, (by) offering lower-cost, high-deductible health plans.”¹

The IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. There are out-of-pocket expenses with high-deductible plans (for co-pays and coinsurance) that can, when combined with deductible expenses, reach over $6,000 for an individual and over $13,000 for a family. When you add the cost of monthly insurance premiums to all the out-of-pocket expenses, medical bills can be overwhelming.

Health providers are frequently caught in the middle of the patient who can’t pay, and the insurance payor who won’t pay because there is money owed on a deductible. Healthcare providers are depending more and more on patient payments and finding new strategies to deal with collecting fees.

Offices are making it easier to pay. Many provider’s offices make it convenient for a patient to pay, resulting in an overall boost to payments. Payments are made through their website, via touch-tone if a patient is calling, and even as a response to a text message reminder to pay.

If your organization is struggling with patient payments, it is important to put policies and technology in place as soon as possible. High-deductible plans are certainly not going away, and will likely increase in the near future.

What sets our Orthopedic Team apart is our real-world experience in the medical revenue cycle and our in-depth knowledge of WHY things happen the way they do. I think one of the BIGGEST challenges in finding good medical billers is that they are often trained only by the person who sat in their chair before them. Our team actually have over 22 years experience in Medical Billing/Coding with strong A/R background that gives our team a depth others simple don’t have.

Yes, you read that correctly. There are cases when it is appropriate to bill the patient when a claim is denied because there are specific denials that a physician’s office cannot rectify. An example is a denial for coordination of benefits. Even if the business office knows who the correct primary payor is, and called the insurance company to sort things out, the insurance company won’t change a thing on the patient’s account. That is because insurance contracts are between the patient and the insurance company. Only the patient has the authorization to manage his or her account. After receiving a bill for the denied services, the patient needs to call his/her insurance companies to sort out primary and secondary coverage, and then contact the healthcare provider’s office to let them know who needs to be billed as primary.

If you have not already done so, confirm that you have a BAA with each of your business associates to make sure that your patients are protected. You may want to create a checklist for each business associate that confirms you have received the contract, scope of work, and BAA. It can also be handy to include information such as your business associate’s compliance officer and contact information should the need to communicate arise. Since it is not uncommon for providers to have turnover in business offices, it is best practice to designate the place where all vendor contracts and information are kept so that it can be found easily and quickly.

Both personally and professionally, Charmaine is dedicated to bettering the lives of those in her community. Proud to be the founder and proprietor of a woman-owned business, Charmaine prides herself in assisting other women in reaching their full potential as well as their professional goals

The Club offer programs, meetings, events, networking, and resources teach simple strategy to achieve success for the dynamics of today’s economic. Supporting the community building confidence, achievement, professionalism, knowledge, skills, and motivation through social, educational, and empower development.

You will never experience true success until you learn to embrace failure. Your mistakes pave the way for you to succeed by revealing when you’re on the wrong path. The biggest breakthroughs typically come when you’re feeling the most frustrated and the most stuck. It’s this frustration that forces you to think differently, to look outside the box and see the solution that you’ve been missing. Success takes patience and the ability to maintain a good attitude even while suffering for what you believe in.