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...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, has the potential to spawn large government recoveries against plans that ripple down to plan action against downstream providers.
Continue Reading...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 final rule will affect payments for dialysis treatments furnished on or after January 1, 2012 under the bundled ESRD Prospective Payment System that was implemented in calendar year 2011. CMS estimates that payments to ESRD facilities will total $8.3 billion next year.
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 to point these distinctions to the surveyors and avoid any confusion and resulting deficiencies.
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 nine Americans receiving coverage for their medical care through WellPoint’s affiliated plans. CareMore, based in Downey, California, is a physician owned medical group operating Medicare Advantage plans in California, Arizona and Nevada with the majority of its membership in California.
By Karie Rego
A new Medicare program laboratory demonstration project starts July 1, 2011 and provides some additional revenue for hospital or independent labs.
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 overpayments and possible penalties as false claims), many providers hesitate to undertake audits even though the OIG consistently cites the criteria in its annual work plans. However, finding and reducing the risk associated with the criteria is very important.
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