Reimbursement Archive

Anthem BCBS of Indiana Climbs On Board the Pay-For-Performance Bandwagon

Medicare implemented its Physician Quality Reporting Initiative,which is also known as PQRI. Doctors who satisfied the quality of care and reporting requirements under PQRI received bonuses equal to 1.5% of their 2007 reimbursements. A very limited number of small to medium size practices have opted to participate in PQRI due to the onerous reporting requirements

Medicare to Stop Paying for Certain “Never Events”

Beginning tomorrow, Medicare will no longer provide reimbursement for certain newly added “never event.” In particular, Medicare will refuse to provide reimbursement for the following conditions: Surgical site infections following certain elective procedures Legionnaires’ disease Extreme blood sugar derangement Lung collapse (Iatrogenic pneumothorax) Delirium Ventilator-associated pneumonia Formation/movement of a blood clot (Deep vein thrombosis/Pulmonary Embolism)

Payer Acknowledges Improper Out-of-Network Reimbursements

New Jersey patients and providers recently enjoyed a victory in their long-running tug-of-war with payers concerning the reasonableness of out-of-network reimbursements. Last Tuesday, the New Jersey Department of Banking and Insurance (“DOBI”) announced that Healthnet of New Jersey has agreed to pay $41 million to settle charges that it systematically underpaid out-of-network providers between 1996

After years of Litigation, E/M Denials Persist

Notwithstanding years of litigation and multi-million dollar settlements, many healthcare providers continue to experience inappropriate evaluation and management service (“E/M”) denials. Earlier today, I spoke with a provider who had a well-founded complaint regarding his denials, so I want to take a minute to quickly review the basics. E/M is a visit or consultation provided

New Jersey Lawmakers Cap Self – Pay Charges

Uninsured New Jersey patients will soon be seeing lower hospital charges. Earlier this week, New Jersey’s governor signed into law Assembly Bill 2609, which caps the fees that hospitals can charge uninsured patients. According to the New Jersey Commission on Rationalizing Health Care Resources, the constraints contained in this new law will cause a decrease

Reimbursement Denials Expanded for Medical Errors

As we discussed earlier this year, Medicare has created an ever expanding list of hospital-acquired conditions for which it no longer provides reimbursement. This list includes conditions such as 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

How to Earn Your Electronic Prescribing Bonus

In recent blogs, we focused on Congress’ carrot and stick approach to encourage e-prescribing. As we discussed, providers who implement e-prescribing could receive Medicare bonuses (above and beyond the Medicare fee schedule payments) equal to 2% of their annual Medicare collections. However, providers who do not implement e-prescribing will eventually see their reimbursements drop below

Electronic Prescribing: Medicare Bonuses and Penalties

While we have seen many news stories regarding H.R. 6331’s rollback of the scheduled 10.6% Medicare reimbursement cuts, there has been virtually no coverage regarding the bill’s groundbreaking provisions calling for Medicare bonuses for providers who adopt and regularly utilize electronic prescribing. Therefore, let’s take a few minutes to discuss some of the basics. H.R.

Congress Stops Medicare Cuts and Creates E-Prescribing Bonus

By a veto-proof, bipartisan majority, Congress has just passed H.R. 6331, which will rollback the 10.6% Medicare reimbursement cuts that were scheduled to become effective today and provide an incentive to physicians who adopt and utilize electronic prescribing technology. Background regarding the Scheduled Cuts The Centers for Medicare & Medicaid Services (“CMS”) final 2008 Medicare

Significant Health Law Developments

During the last twelve months, we’ve seen significant developments in health law. At today’s opening session of the annual meeting of the American Health Lawyers Association, we took stock of many of these developments, which include the following: Medicare Cuts Saga Continues to Unfold. On June 30th, we witnessed the latest chapter in the Medicare