Category Archives: Academy Blog

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CMS limits of scope of MAC/QIO review for appeals

“Scope Creep” in Appeals is Dead CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. For redeterminations and reconsiderations of claims denied following a complex prepayment … Continue reading

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NEWS POLL Friday February 17 2017

NEWS POLL Friday February 17 2017 See the article below and then take our poll, below… U.S. DOJ sues UnitedHealth Group over alleged Medicare overcharges To VOTE, simply click on a box below to add your vote. To Change your … Continue reading

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Nominee Tom Price Wants Shift Away from Medical Necessity Audits To Anti-Fraud Audits

CMS should focus its billing audits less on verifying medical necessity and more on rooting out blatant fraud, the agency’s likely next secretary said Tuesday. Rep. Tom Price, R-Ga., made statements to that affect while appearing before the Senate Finance … Continue reading

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CMS Updates Hospital Appeals Settlement

CMS posted a notice on their website today stating that they will reopen the Hospital Appeals Settlement process. No dates or other details are yet available, but “will be released in the near future,” according to the post. Apparently, a … Continue reading

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Medicare’s Efforts To Curb Backlog Of Appeals Not Sufficient, GAO Reports

By Susan Jaffe  | June 10, 2016 | Original post at Kaiser Health News Republished by permission. Despite interventions by Medicare officials, the number of appeals from health care providers and patients challenging denied claims continues to spiral, increasing the … Continue reading

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CMS Delays JW Modifier and Tells QIOs to Re-Review Denials

A representative of CMS stated that the July 1 2016 deadline for required use of the JW Modifier to report drug wastage is being moved to January 1 2017, on an Open Door Forum Conference Call, today. A transmittal is forthcoming to confirm the change, they also stated. Continue reading

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Self-Administered Medication – Earned Revenue or Another Write Off

Caveat emptor et provisor [Let buyer and provider beware] Written by Bill Malm, ND CMAS CRCR Many facilities struggle with the implementation and collection of earned revenues from Self-Administered Medications (SAD.)  SAD has had a litany of guidance made by … Continue reading

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FAQs from “JW Modifier and SAD Demystified” Webinars

Questions on New CMS Pharmaceutical Policies “Finally Friday!” hosted a presentation by Bill Malm on Friday, May 20, providing an educational review of the newest Transmittals concerning the reporting and billing of drug wastage and so-called “self-administered drugs” (SAD). The … Continue reading

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CMS Temporarily Pauses Two-Midnight Reviews by QIOs

Reasoning Unclear, Time-frame Indeterminate Audits of Medicare claims concerning the Two-Midnight Rule are temporarily suspended by CMS, to allow CMS to collaborate with the two BFCC-QIO contractors, Livanta and KEPRO, “to ensure consistency in how the rule is applied to … Continue reading

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CMS Offers the MOON to fulfill NOTICE requirements

CMS has developed a standard notice, the “Medicare Outpatient Observation Notice” (MOON) that would include all of the informational elements necessary to fulfill the NOTICE Act’s written notice requirement. Continue reading

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