Since the signing of the Patient Protection and Affordable Care Act (PPACA) last year, there has been considerable attention and interest within the industry towards accountable care organizations (ACOs). Accompanying this focus has been a series of questions regarding the compositional requirements, as well as the operational and structural opportunities to be afforded to (and […]
Wisconsin Physician Services (“WPS”), the Medicare Part B Carrier for providers in Michigan, Illinois, Minnesota and Wisconsin, recently conducted a service-specific probe review of Current Procedural Terminology (“CPT”) 99233 billed by neurology providers. WPS found that only 4 percent of billed claims were payable. 96 percent were denied or down-coded. CPT 99233 is a hospital […]
The recovery audit contractor (“RAC”) for Region B covering the Midwestern states, CGI Federal, Inc., is requesting additional documentation from providers regarding facet joint injections without reported imaging guidance (CPT codes 64470-64476). The requests for additional documentation acknowledge that CMS has not yet approved this issue for complex review and further acknowledge that the RAC […]
A report published in the February 2, 2011 edition of the Journal of the American Medical Association, compared the patient diagnoses, length of stay, and location of service for hospice patients receiving care from for-profit and not-for-profit hospices. The researchers found that for-profit hospices had a higher percentage of patients with non-cancer primary diagnoses, and […]
CMS has issued revised Interpretive Guidelines for the Hospital Conditions of Participation. The revised Interpretive Guidelines, which are effective immediately, contain significant changes affecting anesthesia providers, including the following: • Labor Epidurals. CMS removed language exempting labor epidurals from the physician supervision requirements. The revised Interpretive Guidelines note that, “there is often no bright line, […]
During the Recovery Audit Contractor (“RAC”) demonstration program, a significant number of the claims denied were denied for the reason that an inpatient hospital admission was not medically necessary. The RACs regularly based these denials not upon published Medicare guidance, but based upon the criteria of private companies, such as InterQual. In an effort to […]
The New York regulations related to the credentialing of medical staff personnel have been revised, effective December 22, 2010. In particular, the regulations have been revised to reduce the required “look-back period” for medical staff credentialing from 10 years to five years. During this “look-back period,” hospitals are mandated to query all hospitals at which […]
The FY 2010 Health Care Fraud and Abuse Control Program Report was issued on January 24, 2011 by the Office of Inspector General (“OIG”). This report summarizes the health care fraud prevention and enforcement efforts that yielded results during fiscal year (“FY”) 2010. According to the Report, the federal government recovered more than $4 billion […]
The American Hospital Association (AHA) expressed its concerns with numerous regulations adversely impacting hospitals, by way of letter dated January 14, 2010 to Darrell Issa, the Chairman of the Committee on Oversight and Government Reform in the U.S. House of Representatives. Among numerous other regulations causing strife for hospital providers (e.g., the Federal Stark law, […]
Last week, a lawsuit was filed in the Northern District of Texas federal court, challenging the validity of the aggregate annual cap for hospice reimbursement. Medicare provides reimbursement for hospice services rendered on a per beneficiary, per diem basis, subject to an aggregate annual cap. This cap is based upon the product of a per-beneficiary […]
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