Category Archives: Medicare

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Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015.  Medicare Recovery Audit Contractors (RACs) are prohibited from auditing inpatient hospital claims for compliance with the rule from October 1, 2013, through March 31, … Continue Reading

New Approaches – and Increasing Oversight – for Medicaid Managed Long Term Services and Support

Approximately one-third of Medicaid spending, $136 billion, is on long-term services and supports (LTSS).  While the majority of Medicaid LTSS takes place in institutional settings, such as nursing facilities and mental health facilities, there is an ongoing emphasis on the role of non-institutional facilities. A growing number of states, from 8 in 2004 to 16 … Continue Reading

Ambulatory Surgery Centers Finally Get Some Relief

By Aleah Yung On Saturday, September 22, 2012, Governor Brown signed SB 1095, which clarifies ambulatory surgery center (“ASC”) pharmacy licensure eligibility. This is great news for ASCs which have struggled since a controversial 2007 court decision had unintended consequences that effected the ability of ASCs to obtain pharmacy licenses.… Continue Reading

New Medicare Advantage Audits Likely to be Challenging for and Challenged by Providers and Plans

By Karie Rego Since the 2006 payment year, CMS has conducted Risk Adjustment Data Validation (RADV) audits on Medicare Advantage (MA) plans’ risk adjustment payments. However, CMS has been hindered by the lack of a methodology to extrapolate audit results. On February 23, 2012, CMS posted its final error calculation methodology. This methodology, if implemented, … Continue Reading

Medicare Issues Final Rule for the End-Stage Renal Disease Prospective Payment System

By Lynsey Mitchel The Centers for Medicare and Medicaid Services (“CMS”) released a final rule on November 1, 2011, that will update Medicare policies and payment rates for dialysis facilities. According to CMS these provisions will strengthen “incentives for improved quality of care and better outcomes for beneficiaries diagnosed with End-stage Renal Disease (“ESRD”). The … Continue Reading

Termination from Medicare and Medicaid Programs Due to Confusion Over Standards

By Karie Rego It is important for home health agencies and other providers that serve both Medicare and Medicaid populations to be aware of the differences in requirements. With the reductions in staffing, surveyors may be reviewing more than one program. We recommend a review of the different legal requirements and keeping information on hand … Continue Reading

Insurer to Purchase Vertically Integrated Medicare Advantage Plan/Provider

By Eric Klein and Aytan Dahukey WellPoint, one of the nation’s largest health insurers, has agreed to buy CareMore for approximately $800 million. WellPoint, which holds the license for Blue Cross in California and for Blue Cross Blue Shield in several other states, is the largest American health insurer in terms of patients covered, with one in … Continue Reading

Finding and Fixing Provider-Based Criteria Problems

By Karie Rego The Medicare provider based criteria have been around for over 10 years but still raise cause for concern. Basically on or off campus patient care locations that meet the criteria get to bill at higher hospital rates. Because the implications of not meeting the provider based rules are great (the assessment of … Continue Reading
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