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MiraMed’s eAlerts are distributed via email every Wednesday, and contains the latest industry information regarding business process outsourcing solutions, helpful coding news, or any number of relevant topics in the fast-paced, ever-evolving world of healthcare. To subscribe, simply complete the form below. Below the subscription form, you will find the archived eAlerts available.

November 14, 2012

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) issued its 2013 Final Physician Fee Schedule (Final PFS).  Included within the Final PFS is discussion about the omnipresent Sustainable Growth Rate (SGR) formula, increase in payments to primary care physicians (PCP), an expansion of the multiple procedure payment reduction (MPPR) policy, and revisions to the new value-based payment modifier proposal.

Read more: Final 2013 Medicare Physician Fee Schedule Issued

November 7, 2012

Hospitals often face challenges related to on-call coverage by their specialist physicians.  In fact, fears of violating State and Federal fraud and abuse laws typically steer hospitals away from putting systems in place to encourage call coverage by their specialists.  However, the Department of Health and Human Services Office of Inspector General (OIG) issued an Advisory Opinion last week (No. 12-15) wherein it viewed favorably an arrangement involving per diem compensation for on-call coverage.

Read more: The OIG’s Most Recent Guidance Regarding Compensation for On-Call Physician Coverage

October 31, 2012

In the October 4, 2012 Alert, we cautioned against the policy of routinely waiving patient co-insurances and deductibles because of the various laws that have been enacted by the Federal and State governments to deter such practices. While much of the recent emphasis has been on the government’s actions, insurance companies, competitors and private individuals are also taking the initiative by filing civil actions against providers who attempt to attract business by offering discounts, including the waiver of patient co-insurance and deductibles.

Read more: Payors and Private Parties Take Action Against Providers That Routinely Wave Patient Coinsurance...

October 24, 2012

On the heels of our last alert, a new bill was introduced by Rep. Sam Graves (R-Mo.) along with Reps. Todd Akin (R-Mo.), Billy Long (R-Mo.) and Adam Schiff (D-Calif.) in the US House of Representatives, the Medicare Audit Improvement Act of 2012 (HR 6575).  HR 6575 aims to put forth a more structured process for recovery audit contractors (RACs) while also holding their feet to the fire when certain program requirements are not met.  Even as we discussed the audit appeals process last week, in light of this recent bill, it may be beneficial to take one step back and look at the current RAC process (which is the precursor to the appeals), and focus on the proposals of this new bill.

Read more: The Medicare Audit Improvement Act of 2012—Is There Hope for Part A Providers Facing Medicare...

October 17, 2012

The Centers for Medicare and Medicaid Services (CMS) has a number of audit tools at its disposal to protect the integrity of State and Federally-funded healthcare programs.  Included in those tools are Program Safeguard Contractors and Zone Program Integrity Contracts, which identify fraud, abuse and waste in the Medicare program;  Medicare and Medicaid recovery audit contractors, which identify improper payments (e.g., overpayments and underpayments) made to providers and suppliers; and Medicaid Integrity Contractors, which identify fraud, abuse and waste in the Medicaid program.  With the increased focus on compliance and fraud and abuse, providers and suppliers are finding that, even with effective and appropriate compliance programs in place, they still experience audits by CMS contractors and claim denials.  However, providers and suppliers should be aware that claims denials may be successfully appealed through the appeals process. This alert describes the five levels of appeal a provider or supplier could face when appealing a claim denial under the Medicare program.

Read more: Appealing Claims Denials Under the Medicare Program

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