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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.

Appealing Claims Denials Under the Medicare Program

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.

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The Office of Inspector General (OIG) 2013 Work Plan: The OIG’s Upcoming Initiatives

October 10, 2012

Each year, the Department of Health and Human Services (HHS) OIG issues a Work Plan wherein the OIG summarizes new and ongoing reviews and activities that it intends to pursue with respect to HHS programs and operations during the upcoming fiscal year.  On October 2, the OIG issued its Work Plan for 2013 and in it included both a renewed focus on existing reviews as well as new efforts for 2013.

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Seven Serious Concerns with Routine Waiver of Patient Coinsurance Amounts

October 4, 2012

At the 2012 American Health Lawyers/Health Care Compliance Association Fraud and Abuse Conference recently held in Baltimore, Maryland, it was surprising to learn that this issue is still resulting in confusion and concerns.  Some physicians are being approached by “companies and health care entities” that do not participate in specific insurance programs.  As a result, when the physician works at their facility they request that the physician accept any health insurance payment received on the professional side as payment in full.  These types of arrangements may be considered abuse and potentially implicate the anti-kickback rules.  Here are seven reasons to say no to these requests.

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New HIPAA Rules Coming Soon

September 27, 2012

Health care providers will soon be receiving  major updates to the Health Insurance Portability and Accountability Act (HIPAA) that were created by the Health Insurance Technology for Economic and Clinical Health Act (HITECH).   The new HIPAA Rule is expected to be finalized and published to the Federal Register sometime later this year and contains key provisions that need to be incorporated into all health care entities HIPAA compliance program. Some of these anticipated changes include:

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