News & Information

CNN reported an astounding number of individuals charged with false billing. There was about $900 million in false billing that involved Medicare and Medicaid fraud. Along with the $900 in false billing, $36 million in Detroit involved a front for a narcotics diversion scheme. There were 301 defendants charged in the United States involving 61 medical professionals’ 36 Federal Judicial districts and 28 doctors were charged.

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Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:

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Medicare is implementing a three year Pre-Claim Review Demonstration of Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.

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The preliminary list of the new ICD-10- CM codes that become effective October 1, 2016 have been released. There are approximately 1600 changes to the code set, making up for the years the ICD-10- CM codes have not had updates.

For FY 2017, many changes have occurred in the ‘O’ Chapter, which consists of codes for the antepartum (first, second, and third trimesters), intrapartum and postpartum (puerperium] - 6 weeks after delivery) periods of a pregnancy.

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To help the understanding of what is covered under Dental and what may be covered under Medical, review Regence's coverage criteria:  

Coverage under medical or dental benefits is determined by the condition that is being diagnosed and treated, regardless of whether the service is provided by a dentist or a medical doctor.

MEDICAL POLICY CRITERIA

Note: Member contracts for covered services vary. Member contract language takes precedent over medical policy.

I. Dental Services

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