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CMS and OIG Revisit EHR Software Exception and Safe Harbor

April 17, 2013

On April 10, the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) both issued proposed rules regarding arrangements involving electronic health records (EHRs) under the physician self-referral statute (Stark Law) and the Anti-Kickback Statute (AKS). Both the Stark Law and AKS currently have exceptions for certain arrangements involving the provision of EHR software to physicians in a position to refer patients back to the facility and are facing proposed changes.

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The National Commission on Physician Payment Reform

April 10, 2013

For the last 15 years, the physician payment policy that has been closest to home for practicing physicians has involved repeated down-to-the-wire congressional interventions to avert large Medicare payment rate cuts specified by the sustainable growth rate (SGR) formula. Less visible, but potentially as important or more important over the longer term, has been a series of steps to revamp the resource-based relative value scale (RBRVS) which is the foundation of the Medicare Physician Fee Schedule (MPFS), with the goal of more accurately reflecting the relative costs of providing different physician services. The 2010 Patient Protection and Affordable Care Act (ACA) authorized initiatives to explore broader payment reforms such as accountable care organizations and bundled payments. Although the focus of physician-payment policy has been the Medicare program, the impact is much broader, since private insurers and Medicaid programs incorporate many of the Medicare changes into their systems of payment to physicians.

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Questions and Answers Regarding the 2% Medicare Payment Cut and How it Will Impact Healthcare Providers

April 4, 2013

MiraMed Global Services (MMGS) is receiving some very good questions from our clients regarding more details on how the sequestration 2% Medicare payment cut will impact their reimbursement. We are continuing to monitor CMS and Medicare carriers’ websites, including Palmetto, CGS, Novitas, First Coast Service Options and NHIC.

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Enforcement Discretion Ending for Insurers to Support HIPAA Transactions for Patient Insurance Eligibility Verification and Claim Status

April 3, 2013

The discretionary enforcement period, instituted by the Centers for Medicare & Medicaid Services (CMS) on January 1, is scheduled to end March 31 for operating rules that support the HIPAA transactions for patient insurance eligibility verification and claim status. Although the Affordable Care Act (ACA) required health plans and others to comply by the first of this year, CMS decided it would not initiate enforcement action until April 1. After March 31, health plans will be required to comply with a series of business rules, making it possible for practices to identify, for example, patient co-pays and remaining deductibles within 20 seconds of sending the electronic request to the health plan.

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OIG Turns its Attention to Physician-Owned Distributorships

March 27, 2013

In its first new Special Fraud Alert in the past decade, the Office of Inspector General (OIG) focused its attention on physician-owned entities deriving revenue from selling, or arranging for the sale of, implantable medical devices ordered by their physician-owners, commonly known as physician-owned distributorships or PODs.  The issue of whether PODs are permissible under the Federal fraud and abuse laws has been an issue of debate as of late.  In fact, in light of the controversy, in 2011, the Senate Finance Committee issued letters to the OIG that insisted the two bodies to take a position and issue guidance on PODs and how they fit within the current legal structure governing healthcare transactions and relationships.  The Special Fraud Alert: Physician-Owned Entities (Alert) appears to be a response to the 2011 letter to the OIG.

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CMS’s New Part B Rebilling Rule and its Impact on Hospitals

March 20, 2013

Typically, when a patient presents at a hospital in need of care, the physician (or other qualified practitioner) may either admit the patient for inpatient care or treat the patient as an outpatient.  Oftentimes, when the patients are admitted as an inpatient, an audit conducted by Medicare auditors and contractors (e.g., Medicare Administrative Contractors (MACs), Recovery Auditors (RAs) or Comprehensive Error Rate Testing (CERT) Contractors) results in denial of the Part A claims as not being reasonable and necessary.  Currently, hospitals may bill a subsequent Part B inpatient claim for a limited set of medical and other health services, commonly referred to as “Part B inpatient” or “Part B  only” services, even if additional services furnished would have been medically necessary had the beneficiary been treated as an outpatient.  The American Hospital Association, alongside Missouri Baptist Sullivan Hospital, Munson Medical Center, Lancaster General Hospital and Trinity Health Corporation filed a law suit in November of last year regarding this issue of denials for Part A claims.  

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Strategies for Reducing Hospital Readmissions

March 13, 2013

The issue of reducing hospital readmissions has been one that hospitals and physicians have faced for years.  However, with the passing of the Patient Protection and Affordable Care Act (PPACA), the issue has become much more personal.  Now, hospitals with higher-than-expected readmission rates must be penalized. 

The issue of reducing hospital readmissions has been one that hospitals and physicians have faced for years.  However, with the passing of the Patient Protection and Affordable Care Act (PPACA), the issue has become much more personal.  Now, hospitals with higher-than-expected readmission rates must be penalized. 

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Are Your Computer and Mobile Networks Secure Enough for Today’s Healthcare Environment?

March 6, 2013

While much of the healthcare world has been focused on the Health Insurance Portability and Accountability Act of 1996 (HIPAA), especially with the release of the new omnibus rule, it is not without good reason.  In a recent publication in the New England Journal of Medicine, Protecting Patient Privacy and Data Security, Julie K. Taitsman, MD, JD, Christi Macrina Grimm, MPA and Shantanu Agrawal, MD—all of who work for the Office of Inspector General (OIG)—state that the issue of privacy and security of patient information is still at the forefront of the government’s focus.

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The Countdown to Sequester and the Impact on Healthcare

February 27, 2013

This Friday, March 1, marks the day in which across-the-board spending cuts (to the tune of $85 billion) take effect.  Regardless of one’s political position and opinion, it is undeniable that the impact on the healthcare industry will be great. This alert summarizes some of the anticipated affects the sequester will have on the industry.

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CMS Sunshine Act Regulations Released: Is The Grass Always Greener Where the Sun Shines?

February 20, 2013

Section 6002 of the Affordable Care Act (ACA) requires certain applicable manufacturers of drugs, devices, biological or medical supplies to annually report to the Secretary of Health and Human Services (Secretary) certain payments or other transfers of value to physicians and teaching hospitals.  Moreover, applicable group purchasing organizations (GPOs) must disclose any ownership or investment interests in such entities held by physicians or their immediate family members as well as information on payments or other transfers of value to such physician owners or investors.  This law is commonly referred to as the “Sunshine Act”. 

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CMS Proposes to Clean Up its Regulations

February 13, 2013

Yes, you read that correctly.  The Centers for Medicare and Medicaid Services (CMS) has identified certain regulations as unnecessary, obsolete, or excessively burdensome and proposes to “increase the ability of health care professionals to devote resources to improving patient care, by implementing or reducing requirements that impede quality patient care or that divert resources away from providing high quality patient care.”  CMS’s proposals are set forth in a proposed rule that was published in the Federal Register on February 7 (Proposed Rule).

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CMS Announces Groups Participating in Bundled Payments Initiative

February 6, 2013

On January 31, 2013, the Centers for Medicare and Medicaid Services (CMS) announced the healthcare organizations it selected to participate in the Bundled Payments for Care Improvement Initiative (Initiative). The Initiative will test how bundling payments for certain episodes of care can result in increased coordination of care for beneficiaries and decreased cost to Medicare. According to CMS, the Initiative intends to achieve the following:

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Disclosures of Protected Health Information in Light of Recent Tragedies

January 30, 2013

In light of the recent Office of Civil Rights (OCR) Health Insurance Portability and Accountability Act of 1996 (HIPAA) final rule that was recently released, many healthcare providers and suppliers have been put on the defensive when it comes to the use or disclosure of protected health information (PHI), especially because of the increased penalties for violating the rules. Moreover, considering the recent tragedies that have shocked our country, including the shootings at Newtown, CT and Aurora, CO, the issue of disclosures of PHI to protect against such tragedies has been raised. On January 15, the OCR issued a message to healthcare providers reminding them that the Privacy Rule does not prevent a covered entity’s ability to disclose necessary information about a patient to law enforcement, family members of the patient or other persons when there is a belief that the patient presents a serious danger to him/herself or other people.

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OCR Issues Final HIPAA Breach Notification Rule

January 23, 2013

On August 24, 2009, the OCR issued its Breach Notification Interim Final Rule. After nearly three-and-a-half years later, on January 17, 2013, the Office for Civil Rights of the US Department of Health and Human Services (OCR) issued its long-awaited Modifications to the HIPAA Privacy, Security, Enforcement and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act (Final Rule). The Final Rule is to be published in the Federal Register on January 25.

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Hospital Payments of Performance-Based Bonuses to Physician Groups Viewed Favorably by OIG

January 16,2013

In its most recent Advisory Opinion (No. 12-22), the Office of Inspector General (OIG) viewed favorably an arrangement wherein a cardiology group’s compensation from the hospital comprised, in part, a performance-based bonus (Arrangement). The performance bonus is based on certain patient service, quality and cost savings measures associated with procedures performed at the hospital’s cardiac catheterization laboratories.

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2013: What to Expect on the Road Ahead

January 9, 2013

While 2012 left the healthcare world spinning, 2013 does not show promise of slowing down anytime soon. As healthcare providers position themselves for a new year, they should bear in mind some of the following, which are expected to send waves through the industry this year.

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ICD-10—Despite Delays in the Implementation Deadline, Planning and Preparation Now Are Key to Future Success

January 2, 2013

ICD-10 implementation and the need for preparation has been discussed for years. However, the repeated delays in deadlines for the transition from ICD-9 has provided the false sense of security that it is possible to continue to postpone the steps necessary for implementation. Due to the complexity of ICD-10 implementation and the time necessary to coordinate the steps for a successful go-live date by October 1, 2014, organizations cannot wait to see if the Department of Health and Human Services (“HHS”) will again postpone the ICD-10 deadline.

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Incident-To Services: A Recap

December 26, 2012

The issue of “incident to” billing arises when physicians and certain other practitioners seek to be paid for services that are furnished incident to their services. The purpose of this alert is to review the requirements for incident-to billing both in the non-institutional and institutional settings.

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Medicare Secondary Payer—Navigating the Trenches

December 19, 2012

Understanding what to do when a patient presents with multiple payers can be an administrative and billing nightmare. Fortunately, the Centers for Medicare and Medicaid Services (CMS) recently issued a Medicare Learning Network Fact Sheet entitled Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff wherein it clarified billing for services furnished to patients that have health insurance coverage in addition to Medicare.

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Approaching the “Cliff” Regarding the Quickly-Approaching Fiscal Cliff

December 12, 2012

It is difficult to avoid hearing or talking about the fiscal cliff—an impending tax-hike-and-spending-cut disaster that is set to take effect in less than one month. While Washington appears to be dancing to a familiar routine, the rest of the country is sitting on the edge of its seat wondering when it will see the end of this number and what it will bring. Generally, Republicans propose severe cuts to spending and limited, if any, tax increases, while Democrats propose limited spending cuts and steep tax hikes for upper income earners. Amidst all of this debate, it is hard to discern where healthcare fits into the picture. Unfortunately, while navigating through the labyrinth of information, we find little concrete guidance.

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Could Pre-Payment Audits for EHR Incentive Payments Be on the Horizon?

December 5, 2012

Since 2011, over 84,000 physicians and hospitals have claimed about $4 billion in incentive payments for meaningfully using certified electronic health record (EHR) programs. Estimates revealed that the government will be paying eligible physicians and eligible hospitals nearly $7 billion in total incentive payments by 2016. Because the aggregate incentive payments are so great, the Office of Inspector General (OIG) conducted an audit and issued a report, Early Assessment Finds that CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program (Report), which analyzes the fraud and abuse vulnerabilities in the EHR inventive program. The Report focused on the Medicare incentive payments and did not discuss Medicaid incentive payments.

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