Documents concerning payment of Part B despite a Part A Denial A February 1, 2010 decision by the Medicare Appeals Council (Council) found in favor of the appellant (O’Connor Hospital in San Jose, CA). This decision is consistent with a March 14, 2005 decision by the Council, which found in favor of that appellant (University […]
OIG Report on Recovery Audit Contractors’ Fraud Referrals Download the complete report HERE Excerpts from EXECUTIVE SUMMARY OBJECTIVES To determine the extent to which: recovery audit contractors (RAC) referred cases of potential fraud to the Centers for Medicare & Medicaid Services (CMS) during the demonstration project, and CMS provided training to RACs regarding fraud identification […]
Modification to Accommodate the Acute Care Episode (ACE) Demonstration from the CMS website: Pub 100-19 Demonstrations SUMMARY OF CHANGES: The Centers for Medicare and Medicaid Services (CMS) issued change request (CR) 6001 on June 27, 2008 to implement the necessary requirements for the ACE demonstration project. Under the ACE demonstration, CMS is issuing a single […]
FAQs on Observation, Condition Code 44 from the CMS website QUESTION: May a hospital report drug administration services, such as therapeutic infusions, hydration services, or intravenous injections, furnished during the time period when observation services are being reported? ANSWER: The Medicare Claims Processing Manual (Pub 100-4), chapter 6, section 290.2.2 states that “observation services […]
What is the CMS Medically Unlikely Edit (MUE) program? The CMS Medically Unlikely Edit (MUE) program was developed to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature […]
The FTC announced on Oct. 30 that it will once again extend the enforcement deadline for the identity theft Red Flags Rule, giving financial institutions and creditors (including health care organizations that bill patients after the completion of services) until June 1, 2010, to address the issue. See the complete press release here.
CMS has guidelines for what to do if certain services are denied under a Part A claim — some services may still be paid under a Part B claim, but all other rules must still be followed, especially including the rule for timely filing. Below are relevant chapters from the CMS Manuals. List of Part […]
Fees Could Better Reflect Efficiencies Achieved When Services Are Provided Together Highlights of GAO-09-647, a report to congressional requesters, dated July 2009 Download the full report HERE (PDF format, 35 pgs, 962 KB) [The following text is directly from page 2 of the GAO Report GAO-09-647] Why GAO Did This Study Medicare’s physician fees may […]
MLN Matters Number: SE0801 Revised Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A [The following is copied directly from this MLN Matters posting by CMS.] Note: This article was revised on November 17, 2015, to add a reference to MLN Matters® […]