Medicare/Medicaid Archive

CMS Proposes Doubling the Number of Non-reimbursable Hospital-Acquired Conditions

My August 13, 2007 blog discussed CMS’ then-groundbreaking move to deny reimbursement for seven hospital-acquired conditions including pressure ulcers, hospital falls, certain catheter-associated infections, air embolism as a result of surgery, leaving an object in during surgery, providing incompatible blood or blood products and mediastinitis following coronary bypass surgery. CMS has now announced that it

Medicare Authorizes Missed Appointment Charges

It is increasingly common for physicians to charge their patients a fee for missed appointments. For example, approximately 31% of MTBC’s clients routinely charge a missed appointment fee. Most of these providers charge approximately $25, while others charge as little as $15 or as much as $100 per missed appointment1. Until recently, there has been

Court Decision Supports Data Mining of Provider-Patient Encounter Details

In a decision that could have broad implications for physicians and patients alike, the United States District Court for the District of Columbia has recently ordered the Centers for Medicaid and Medicare Services (“CMS”) to disclose claim information regarding hundreds of thousands of patient encounters. The Lawsuit In March 2006, Consumers’ Checkbook, a consumer group

Medicare will Deny Claims Relating to Hospital-Acquired Conditions

Newly adopted Medicare regulations make it clear that Medicare intends to stop reimbursing hospitals for expenses associated with “hospital-acquired conditions”. Background Pursuant to the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Secretary identified certain high cost and/or volume preventable conditions that result from inadequate hospital care and are identifiable by unique ICD-9-CM codes.

NJ DOBI Orders Aetna to Properly Reimburse Non-participating Providers

Last week, the New Jersey Department of Banking and Insurance (“NJ DOBI”) entered an order requiring Aetna to pay a fine of $9,457,500 for violating New Jersey’s HMO regulations regarding reimbursement for services rendered by non-participating providers. New Jersey HMO Law Pursuant to New Jersey law, an HMO must limit its members’ liability for services

Why utilize ERAs and EFTs?

A provider recently asked me whether she should register to receive Electronic Funds Transfer (“EFT”) and Electronic Remittance Advice (“ERA”) for her Medicare Part B claims. I answered “yes” and also encouraged her to consider registering for EFT and ERA with regard to any other payers with whom she participates. Since so many providers have

Hospitals Consider Discounts for Needy Patients as Costs Soar

Major medical technology advances over the last two decades have significantly improved the quality of care received by hospital patients. However, the use of technology has also resulted in increased costs and many of the underinsured or uninsured ‘working/retired poor’ have been priced out of the market. In a recent RAND Health report, Dana Goldman,

How to Earn Your PQRI Bonus

My last two blogs addressed the ‘what’, ‘when’ and ‘why’ aspects of PQRI (if you haven’t yet read them, you may want to do so prior to reading today’s blog). Today’s blog focuses on the issue of how a health care provider can obtain a PQRI bonus. You are not required to formally register in

Now is the Time to Get Ready for PQRI

As of July 1, 2007, providers must begin reporting information regarding certain quality measures (I’ll describe this in greater detail tomorrow). While the official kickoff for reporting activities is still months away, NOW is the time to make certain that you will be ready. If you are using an EMR, your new reporting responsibilities will

CMS Relaxes NPI Deadline

The Centers for Medicare & Medicaid Services (CMS) has just announced that it is relaxing the enforcement of its May 23, 2007 deadline concerning the mandatory use of the National Provider Identifier (“NPI”) in conjunction with all standard transactions. Section 1173(b) of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) set into motion