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Medicare Billing and Payment for Telehealth Services

July 30, 2014

Generally, for Medicare payments to be made for telehealth services under the Physician Fee Schedule (PFS) several conditions must be met.  Specifically, the service must be on the Medicare list of telehealth services and meet all of the following other requirements for coverage:

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Off-Campus Provider-Based Departments May Get a New Modifier

July 23, 2014

 

The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2015 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates proposed rule [CMS-1613-P] on July 3, 2014.  The proposed rule would update Medicare payment policies and rates for hospital outpatient department and ASC services, and update and streamline programs that encourage high-quality care in these outpatient settings.  This proposal would continue the progress made so far in moving the OPPS from what currently resembles a hybrid of a prospective payment system and a fee schedule, to a more complete prospective payment system.

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CMS Issues Multiple Fact Sheets Addressing Proposed New Rules

July 16, 2014

 

July is a blockbuster month, if your job requires you to digest and prepare your organization for the ever-changing world of the Centers for Medicare & Medicaid Services (CMS) regulations.  CMS released eight Fact sheets since July 1st containing over 1,000 pages of proposed new regulations to various aspects of the Medicare program.  They cover proposed regulations for everything from the Physician Quality Reporting System (PQRS) to End-Stage Renal Disease (ESRD).  While the Fact sheets provide a good overview of the changes, determining what they really mean to your hospital or organization is, of course, in the details.  Many professional associations tend to spin the generalities and wait until the final regulations are released later this year rather than dive into the specifics of the proposed rules.  On the surface some of the proposed changes appear to be easy to deal with, e.g., plug in the new conversion factor or pull out the 73 PQRS measures that are being deleted. The chart below provides links to the various Fact sheets and the proposed rules.

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Special Fraud Alert: Laboratory Payments to Referring Physicians

July 9, 2014

 

The Department of Health and Human Services Office of Inspector General (OIG) is warning clinical laboratories and physicians that providing remuneration to physicians to collect, process and package patients' specimens and/or establishing databases to collect patient testing data could violate federal anti-kickback law.

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Challenging the United States to Win the World Cup in Health Care

July 1, 2014

 

World Cup fever has struck the United States (US) like never before. Last Sunday evening while navigating a busy airport, the thirty-foot wide hallway was cramped with fans trying to catch a glimpse of the US/Portugal game. Apparently, the game pulled in 20 million viewers, with another 1.4 million watching online on ESPN—figures which exceed the National Hockey League's Stanley Cup finals and are comparable with the NBA finals. It is exciting to see the interest grow for this sport. And when a big event comes up and the US has a fighting chance to compete with the power teams in the world, tens of millions of people will gather to watch. Face it, Americans like to win.

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Hospitals Need to Recognize the Physician’s Role in the Revenue Cycle

June 25, 2014

 

Two recent articles highlight the importance of the physician in the revenue cycle.  The first is a report released several weeks ago by the Office of Inspector General (OIG) on documentation and coding problems with evaluation and management services (E/M).  Internet chatter has been high since the May 2014 release of Improper Payments for Evaluation and Management Services Cost Medicare Billions In 2010 which found that 55 percent of claims for E/M services in 2010 were incorrectly coded and/or lacking documentation.  Medicare inappropriately paid $6.7 billion for these claims, representing 21 percent of Medicare payments for E/M services in 2010.  In particular, 26 percent were upcoded and 15 percent were downcoded.  Let’s repeat the last part of that finding:  15 percent were downcoded at a cost of $1.8 billion in lost revenue!

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Health and Human Services Renews Their Vision for an Interoperable Health IT Infrastructure

June 18, 2014

 

On June 5th the Office of the National Coordinator for Health IT (ONC) released a white paper outlining a 10-year plan to achieve an interoperable health IT infrastructure.  The paper—titled "Connecting Health and Care for the Nation:  a 10-Year Vision to Achieve an Interoperable Health IT Infrastructure”—recognizes the dramatic progress to date in laying a strong foundation of a health IT infrastructure across the United States.  Building on that foundation, ONC believes there is no better time than now to renew the focus on a nationwide, interoperable health IT infrastructure that among other goals, gives patients and providers access to appropriate health information that supports coordinated health management and improves the overall health of the nation’s population.  In short, ONC sees an interoperable health IT ecosystem as one that “makes the right data available to the right people at the right time across products and organizations in a way that can be relied upon and meaningfully used by recipients.”  ONC’s paper pays homage to the advancements made over the past decade, including:

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The Link between Medicaid Expansion and Charity Care

June 11, 2014

 

According to the U.S. Department of Health and Human Services (HHS) more than one million people signed up for Medicaid in April, bringing the total growth since September to about six million.  In 47 states and the District of Columbia, overall Medicaid enrollment reached 65 million last month.  Enrollment for those same states back in September totaled 59 million, according to a report released last week by the Centers for Medicare & Medicaid Services (CMS).1

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Hospitals and Physicians Receive a Reprieve With Meaningful Use Stage 2 Requirements

June 4, 2014

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) announced a proposed rule, on May 20, 2014, that would allow providers more flexibility in how they use electronic health record (EHR) systems to meet meaningful use (MU) requirements and would formally extend the reporting requirements for Stage 2 of the Medicare and Medicaid EHR Incentive Programs.

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CMS Issues Proposed Hospital Inpatient Payment Regulation

May 21, 2014

 

On April 30, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospitals Prospective Payment System (LTCH PPS) in Fiscal Year (FY) 2015.

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Impact of the Telephone Consumer Protection Act on Healthcare Operations

May 14, 2014

 

To further protect consumers from unwanted autodial or prerecorded calls, often referred to as “robocalls,” the Federal Communications Commission (FCC) approved changes to its telemarketing rules, effective October 2013.  Widely viewed as a win for consumers, the FCC’s February 2012 Report and Order was designed to put an end to intrusive telemarketing calls that seemed to regularly occur during a consumer’s dinner hour.  The Order as adopted specifically protects consumers by:

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Federation of State Medical Boards Passes Model Telemedicine Policy

May 7, 2014

 

On April 26, the Federation of State Medical Boards (FSMB) adopted its Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (Model Policy), which “provides guidance to state medical boards for regulating the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services direction to patients via telemedicine technologies.”  The aim of the Model Policy is to remove obstacles based in law and/or regulation to promote the appropriate adoption of telemedicine technologies.

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Two Landmark False Claims Decisions

April 30, 2014

 

The Department of Justice (DOJ) is increasing enforcement on questionable physician arrangements.  Qui tam “whistleblowers” are steering them to new False Claims Act (FCA) cases daily.  Lately, there have been two landmark FCA decisions involving the Stark Law which has alarmed the hospital/physician community. First, was the $238 million award of damages after a jury trial against the Tuomey Healthcare System in South Carolina; and most recently, the tentative settlement with Halifax Hospital in Daytona, Florida.

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Understanding the ZPIC Audits

April 23, 2014

 

Before Health Information Management (HIM), Revenue Cycle Management (RCM) and Compliance Officials start to do the happy dance since they have a break from the Recovery Audit Contractors (RAC) auditors, they should consider using this pause to ensure everyone is on track regarding another, and more serious, the type of auditing underway.

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UConn Looks for Performance Wins Beyond the Basketball Court

April 16, 2014

 

A school whose early mission was agriculture, the University of Connecticut (UConn) has repeatedly represented some of the nation’s best men and women basketball players and coaches. The women’s team again shares a national title with the men as it did in 2004.  Since 1999, the Huskies' men and women have made a combined 17 appearances at the Final Four, more than any other school.

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Challenges of Health Information Exchanges

April 9, 2014

 

The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, provided funding for various activities intended to promote the adoption and meaningful use of certified health information technology.  HITECH identified the importance of the electronic exchange of health information by requiring it as a key element in the definition of meaningful use of certified electronic health record (EHR) technology.1  Specifically, in order to be a meaningful EHR user, providers are to demonstrate that their certified EHR technology is able to electronically exchange health information to improve the quality of health care, such as promoting care coordination.  As such, electronic exchange is of key importance to the U.S. Department of Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services (CMS) EHR programs.

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Congress Passes SGR Fix Along With Delays in ICD-10 and Two-Midnight Rule

April 2, 2014

 

Early Monday evening the U.S. Senate voted to pass the House legislation that will delay the upcoming 24 percent cut in Medicare payments for a one-year “fix” for reimbursement of physician services from March 31, 2014, to March 31, 2015.1  Since 1997, the sustainable growth rate (SGR) has been a thorn in the side of physicians, Centers for Medicare & Medicaid Services (CMS) and Congress.  This latest version of the “doc fix” was voted out of the U.S. House of Representatives on March 27, 2014 to temporarily delay the looming 24 percent cut in Medicare payments for physician services to March 31, 2015, which was set to go into effect on March 31, 2014.2

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Several Lessons to Learn from the Mystery of Flight 370

March 26, 2014

 

Often crisis situations offer a healthy challenge to our creativity, sense of humanity and responsibility.  History has proven that in every industry, from automobile to zoos, executive management and their organization need to be prepared to respond to a crisis situation.  The media frenzy from CNN to the free-fall tweeting of social media; can quickly propel a crisis into a mega-crisis based on the chatter of speculation and the verification, or in the case of Flight 370, non-verification of the facts.  In any disaster from Katrina to Sandy, Toyota floor mats to GMs ignitions, we must ask questions…why, when, what, how?  The many questions surrounding the mysterious event of Flight 370 will continue to be asked, even if we never have solid answers—and likely even if we do.

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RAC Audits Suspension May Ease the Two-Year Hearings and Appeals Backlog

March 19, 2014

 

In a February 17 announcement that took the healthcare community by surprise, the Centers for Medicare & Medicaid Services (CMS) ordered Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) to cease in their requests for additional documentation requests (ADRs) effective February 28, 2014.  As the current RAC contracts are coming to a close, and with CMS under intensifying pressure from healthcare providers, coupled with a massive backlog of cases pending appeal, CMS stated that, “This will give providers a much-needed “intermission” in recovery audits until CMS finalize and select winning bidders for the next round of contracts."1

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President’s Budget Increases Funds for Office of Civil Rights Coincides with Announcement of New Round of Audits

March 12, 2014

 

The Department of Health and Human Services’ Office of Civil Rights (OCR) published on February 24, 2014 an announcement that it will resume its HIPAA compliance audit program. This time around OCR is expanding the program to include both covered entities and business associates.  OCR’s audit plan will start with a survey of 1,200 organizations out of which some number will be selected to be audited. The survey “will gather information about respondents to enable OCR to assess the size, complexity and fitness of a respondent for an audit,” according to the Notice. “Information collected includes, among other things, recent data about the number of patient visits or insured lives, use of electronic information, revenue and business locations.”  Approximately two-thirds of those surveyed will be covered entities, and the remainder, business associates. The Notice stated that the OCR would be accepting comments on its plan until April 25, 2014.1 The OCR’s mandate by the Health Information Technology for Economic and Clinical Health Act (HITECH) includes developing national standards for the privacy of protected health information, the security of electronic protected health information and breach notification to consumers. HITECH also requires OCR to perform periodic audits of covered entity and business associate compliance with the HIPAA Privacy, Security and Breach Notification Rules.

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Expanding the DRG Window

March 5, 2014

 

The Diagnosis Related Group (DRG) “DRG window policy” defines when outpatient services related to inpatient admissions are not paid for separately, but rather are considered to be included in the inpatient lump-sum payment. Under the current DRG window, Medicare and beneficiaries do not pay separately for related outpatient services delivered within three days of an inpatient admission in a setting owned by the admitting hospital. Services that are provided by hospitals that share a common owner (i.e., multiple hospitals owned by the same corporation, hereinafter, called affiliated hospitals) are not subject to the DRG window. In a February 2014 report, the Office of Inspector General (OIG) released the results of their study regarding the substantial savings to Medicare if the DRG window were expanded.

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