Medicare

Whenever there is a high-cost item, CMS has historically evaluated usage to determine appropriateness of billing and this is another example. A Decision Memo was released on February 15, 2018 which included the following changes:

Intensive Outpatient Treatment (IOP)

Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...

Psychiatric Partial Hospitalization Programs

BACKGROUND

Health Risk Assessment

Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar of risk adjustment or HCC codes, it is time to get on board.

60 Day Final Rule

Effective March 14, 2016, the CMS Final Rule regarding the reporting of overpayments took effect. This ruling clarifies the standards that have been unclear for years since the the PPACA created what is called the "60-day rule." The problem has been the unclear standards on what it means to "identify" an overpayment and when the 60 day clock begins running.

Now, the 60-day rule requires anyone who has received an overpayment from either Medicare or Medicaid to report and return the overpayment within the latter of:

Continuing the commitment to greater data transparency, the Centers for Medicare & Medicare Services (CMS) today released privacy-protected data on the prescription drugs that were paid for under the Medicare Part D Prescription Drug Program in 2014. This is the second release of the data on an annual basis, which shows which prescription drugs were prescribed to Medicare Part D enrollees by physicians and other healthcare professionals.

The scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set are available on the 

CMS has noted that several high volume procedure codes are typically reported with a modifier that unbundles payment for visits from the procedure, even though the modifier should only be used for reporting services beyond those usually provided. Therefore, CMS believes the services may be misvalued. As a result, CMS is proposing to prioritize 83 services for review as potentially misvalued.

 

CMS.gov Fact sheet

The Diabetes Prevention Program is a structured lifestyle intervention that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are pre-diabetic.

Overview

Pages

Subscribe to RSS - Medicare