Medicare Appeals Backlog Update: Key Things to Know

medicare appealBy: Matthew Fischer

Aside from the half million already pending before the Office of Medicare Hearings and Appeals (OMHA), OMHA indicates that it receives more appeals each year than its total annual adjudication capacity and has hit its maximum limits given their current resources.  With these numbers, the current estimated wait time is 3 years for an Administrative Law Judge (ALJ) to process an appeal.  Though recent developments in the litigation involving the U.S. Department of Health and Human Services (HHS) and American Hospital Association (AHA) offered little hope for a resolution, OMHA’s implementation of new settlement initiatives may present a better strategic option for appellants.Continue reading

CMS Mail-Order Competitive Bid Supplier Enforcement Changes: Will It Be Enough?

mail order competitive bid pharmacy dme

mail order competitive bid pharmacy dmeBy: Michael Silverman

Ever since the Centers for Medicare & Medicaid Services (“CMS”) announced its DMEPOS Competitive Bidding Program there has been outcry from both providers and consumers. Particularly with respect to Competitive Bidding for the National Mail-Order Diabetic Testing Supplies Program (“National Mail-Order Program” or “Program”), which took effect on July 1, 2013, there has been a concern about the Program’s sustainability and potential for negative implications to beneficiaries. This is largely due to the low reimbursement rates, as set by the bid winning providers, and the possible spillover effect to the Medicare Part B beneficiaries’ access to quality supplies and services. While CMS had safeguards in place when the Program was implemented, many of the regulations have gone largely unenforced. Change is on the horizon as CMS strives to better police its own Program, but is it too little, too late?

In 2011, prior to the implementation of the National Mail-Order Program, CMS tested Competitive Bidding for diabetic testing supplies in nine geographical regions. In these test markets, the payment rates for a vial of test strips were reduced from $34 to $14. CMS’ goal with Competitive Bidding is to reduce costs to the Medicare Trust Fund and beneficiaries, as well as to curb fraud, waste and abuse in the industry. Wanting to ensure that the intentions of the Program were being fulfilled without repercussions, CMS conducted a study on the nine geographical test regions. In its 2012 report CMS stated that there were no negative consequences to the beneficiaries as a result of the Competitive Bidding Program.Continue reading

DMEPOS Medicare Coverage & Reimbursement

DME medicare

DME medicareBy: Michael Silverman

Providers need to comply with all the Medicare ‘red tape’ but need not let fear of non-compliance inhibit their practice from offering Durable Medical Equipment Prosthetics & Orthotics Supplies (“DMEPOS”) to Medicare beneficiaries.

Here’s an overview of the steps providers need to take to enroll as a supplier of DMEPOS with Medicare to be eligible for Part B coverage and reimbursement:Continue reading

Medicare Audit and Appeal Process from A to Z: Challenging Extrapolated Overpayments

ZPIC audit

Medicare claims are processed by organizations (i.e. Medicare Administrative Contractors (“MACs”)) that contract with the Centers for Medicare & Medicaid Services (“CMS”) to act as liaisons between the Medicare program and providers and suppliers.  As CMS continues to evolve its Medicare audit enforcement strategies to reduce fraud and abuse in the system, post payment reviews utilizing statistical sampling still remain as one of its key methods. 

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Medicare Enforcement by Civil Monetary Penalty: A Guide for Medicare Plan Sponsors

medicare civil monetary penaltyBy: Matthew Fischer

The Centers for Medicare & Medicaid Services (CMS) contracts with private companies also known as sponsors to provide Medicare services and benefits under Parts C and D. However, when a sponsor fails to comply with program and/or contract requirements, sponsors are subject to a wide range of enforcement action by CMS. Enforcement and contract actions available to CMS include intermediate type sanctions (i.e., suspension of payment, marketing or enrollment), termination, and most notably, civil monetary penalties (CMPs). Historically, the majority of enforcement action taken involve the imposition of CMPs. Thus, plan sponsors are strongly encouraged to adopt an aggressive compliance plan that includes mock periodic audits in order to prevent potential deficiency findings by CMS.Continue reading

Opioid Crisis: Payor Strategies to Reduce the Harm of Opioids

By: Karina Gonzalez

CMS recently published a white paper entitled “Healthcare Payer Strategies to Reduce the Harms of Opioids.” The white paper was prepared by the Healthcare Fraud Prevention Partnership (“HFPP”), which is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurers, employer organizations and fraud units to reduce fraud, waste and abuse.  The white paper gives information and provides insight on the way payors view addiction treatment.

HFPP identified five actions that should be considered for implementation by all payors as quickly as possible.

  • Train providers on Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain;
  • Promote access to and usage of Medication Assisted Treatment (MAT);
  • Promote the availability of Naloxone;
  • Encourage use of cross-payor data to identify fraudulent, wasteful or abusive practices associated with opioids in order to target corrective actions; and
  • Identify and disseminate effective practices across the healthcare sector.

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The Move to Self-Reporting Continues: Self-Referral Disclosure Protocol

health law complianceBy: James Saling

The Center for Medicare and Medicaid Services (CMS) issued proposed Self-Referral Disclosure Protocol (SRDP) forms and revisions to the regulations on May 6, 2016. This was an additional step in the move for providers to self-report violations of the Stark Law.  Part of the revisions to the regulations came as a result of the final overpayment rule issued earlier this year on February 11, 2016 (60 Day Rule). CMS expects that the SRDP forms will facilitate faster review of a self-disclosure and make it easier for providers to report violations.

The SRDP was established as a result of the Affordable Care Act and is a tool for resolving Stark Law compliance issues. One of the problems with the SRDP is the time that self-disclosures worked their way through the system.  Some self-disclosures have yet to be resolved and were initially made years ago.Continue reading

CMS Sanctions Cigna over Substantial Failures in Medicare Plans

CMS log blueBy: Karina Gonzalez 

Centers for Medicare and Medical Services (CMS) has  banned Cigna from enrolling and selling new Medicare products because of issues with Part C (Medicare Advantage Plans) and Part D (Prescription Drug Program )that increased enrollees out-of-pocket expenses which led to delays or denials  in receiving medical services and prescription drugs.  These sanctions were imposed effective 1/21/2016 because CMS  determined that “Cigna’s conduct posed a serious threat to the health and safety of Medicare beneficiaries.” Continue reading

How to Get Managed Care Companies to Pay For Your Practice's Improvements

managed care moneyBy: Valerie Shahriari

Florida’s providers are buzzing with questions about value based care, asking why now? Is it a fad? Will it really ever be a widespread form of payment? Why does Florida seem farther behind the value based curve than other markets?

While there are more aggressive markets in other parts of the country, the bottom line is this: CMS changes are coming and they will not be stopped.  The government has invested too much money to turn around at this point.  Here are just a few examples of why:

  • The CMS Value Based Program with hospitals is already implemented;
  • Center for Medicare and Medicaid Innovation is piloting NUMEROUS programs covering many physician specialties
  • CMS expanded the Medicare Shared Savings Program to 3 tracks.
  • A new Merit-Based Incentive Payment for Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be apply to payments for services furnished in 2019.

The train has left the station. Providers will now shift from fee for service to value based payments with CMS.  To be successful and still have a profitable business, clinical integration and quality improvements will need to be implemented to improve your practice whether you are hospital based or office based AND whether you are employed by a hospital or in private practice. These changes will be implemented for all of your patients as you will not distinguish in your level of service between patients with managed care as the payor rather than CMS.  This essentially means that managed care payors will reap the benefits of these improvements in your practice.  If you do not have a value based contract in place with the managed care payors they will not be sharing one dime with you.  They will reap the benefits of your improvements AND keep the money!  And by the time you get around to a managed care contract that is value based, the shared savings opportunities will be less than if you began those discussions now. Continue reading

How to Get Managed Care Companies to Pay for Your Practice’s Improvements

managed care moneyBy: Valerie Shahriari, via Healthcare Reimbursement Blog

Florida’s providers are buzzing with questions about value based care, asking why now? Is it a fad? Will it really ever be a widespread form of payment? Why does Florida seem farther behind the value based curve than other markets?

While there are more aggressive markets in other parts of the country, the bottom line is this: CMS changes are coming and they will not be stopped.  The government has invested too much money to turn around at this point.  Here are just a few examples of why:

  • The CMS Value Based Program with hospitals is already implemented;
  • Center for Medicare and Medicaid Innovation is piloting NUMEROUS programs covering many physician specialties
  • CMS expanded the Medicare Shared Savings Program to 3 tracks.
  • A new Merit-Based Incentive Payment for Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be apply to payments for services furnished in 2019.

The train has left the station. Providers will now shift from fee for service to value based payments with CMS.  To be successful and still have a profitable business, clinical integration and quality improvements will need to be implemented to improve your practice whether you are hospital based or office based AND whether you are employed by a hospital or in private practice. These changes will be implemented for all of your patients as you will not distinguish in your level of service between patients with managed care as the payor rather than CMS.  This essentially means that managed care payors will reap the benefits of these improvements in your practice.  If you do not have a value based contract in place with the managed care payors they will not be sharing one dime with you.  They will reap the benefits of your improvements AND keep the money!  And by the time you get around to a managed care contract that is value based, the shared savings opportunities will be less than if you began those discussions now. Continue reading