Tag Archives: Medicare

Government Shutdown Update: Medicare Claims Processing Continues, but Other Key Functions on Hold

The ongoing partial federal government shutdown that began on October 1, 2013 due to the government funding impasse is having a varied impact on health care provider operations. CMS has ordered Medicare Administrative Contractors (MACs) to continue to perform all Medicare claims processing and payment functions during the government shutdown. Some providers may experience the … Continue Reading

Ways and Means Committee Invites Public Comment on Medicare Cost Sharing Proposals

The House Ways and Means Committee is seeking comments on three bipartisan proposals intended to “modernize” Medicare cost-sharing policies. The proposals, which were included in President Obama’s proposed FY 2014 budget, include: (1) reducing premium subsides for wealthier seniors in Medicare Parts B and D (10-year savings of at least $50 billion); (2) increasing the … Continue Reading

Medicare Trustees Forecast Longer Medicare Solvency

On May 31, 2013, the Medicare Board of Trustees released its annual assessment of the financial condition of the Social Security and Medicare trust funds. The Board projects that the Medicare hospital insurance trust fund will remain solvent until 2026, which is two years later than forecast last year. The Board attributes the improved outlook … Continue Reading

Improper Medicare Payments for Unlawfully Present, Incarcerated Beneficiaries

The OIG has discovered that Medicare has paid millions of dollars in benefits for aliens who are not lawfully present in the country and for incarcerated beneficiaries, contrary to program rules. Specifically Medicare made $91.6 million in payments to health care providers for services to approximately 2,600 unlawfully present beneficiaries during calendar years 2009 through … Continue Reading

Obama Administration’s Regulatory Agenda Points to Busy 2013 for HHS

On January 8, 2013, the Obama Administration published its latest semiannual regulatory agenda, outlining planned regulatory initiatives in a number of policy areas. The Federal Register version of the agenda includes only a portion of the regulations in the pipeline, however; the full agenda has been posted on the Office of Management and Budget (OMB) web … Continue Reading

GAO Calls for Improvements in Use of Medicare Prepayment Edits

In light of a continued high rate of Medicare fee-for-service improper payments (8.6% in FY 2011), the GAO recently assessed the use of Medicare prepayment edits and CMS’s oversight of Medicare Administrative Contractors (MACs) that process claims.  In the report, "Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment," the GAO … Continue Reading

OIG Highlights Vulnerabilities in CMS Oversight of the Medicare EHR Incentive Program

The Medicare electronic health record (EHR) incentive program is vulnerable to paying incentives to professionals and hospitals that do not fully meet meaningful use requirements due to gaps in CMS oversight, according to a recent OIG report. Based on a review of CMS’s oversight of self-reported meaningful use of certified EHR technology in 2011, the … Continue Reading

CMS Final Decisions on Recommendations of the Hospital Outpatient Payment Panel on Supervision Levels for Select Services

CMS has released its Final Decisions on the August 2012 Recommendations of the Hospital Outpatient Payment Panel on Supervision Levels for Select Services. The document provides CMS’s final determinations regarding the appropriate supervision levels for 29 individual hospital outpatient therapeutic services, effective January 1, 2013. CMS has determined that 22 of the considered services may … Continue Reading

OIG Releases 2012 Compendium of Unimplemented Recommendations

The OIG’s December 2012 Compendium of Unimplemented Recommendations highlights unimplemented OIG recommendations that the OIG believes represent significant opportunities for action in FY 2013. The report includes recommendations made through FY 2011 that were not fully implemented as of December 2012. The OIG’s priority open recommendations, which in the OIG’s view represent the most significant … Continue Reading

CMS Seeking Comments on Revisions to Coverage with Evidence Development (CED) Policy

CMS is inviting comments on a coverage document entitled “Draft Guidance for the Public, Industry, and CMS Staff Coverage with Evidence Development in the context of coverage decisions.”  CMS’s CED policy provides the framework for conditional Medicare coverage of an item or service while additional clinical data is developed to support a “reasonable and necessary” … Continue Reading

CMS Announces 2013 Medicare Deductible, Coinsurance Amounts

CMS has published notices announcing the 2013 Medicare inpatient hospital deductible and hospital and extended care services coinsurance amounts. The 2013 Part A deductible for hospital inpatient admissions for the first 60 days of care will be $1,184, followed by $296 per day for days 61-90 and $592 per day for stays beyond the 90th … Continue Reading

ACA Medicare Data Sharing Provision Implementation Proceeds

On November 21, 2012, CMS announced that it is entering into contracts with three organizations to implement the ACA’s Medicare Data Sharing for Performance Measurement provision. The provision requires CMS to make available to “qualified entities” standardized extracts of Medicare claims data under Parts A, B, and D for purposes of evaluating provider and supplier … Continue Reading

CMS Highlights Potential National Coverage Determination (NCD) Topics

On November 27, 2012, CMS posted a list of medical items and services that it might consider for future Medicare coverage review, including potential NCD topics. The list is based on public response to CMS’s previous request for feedback on items and services that may be inappropriately used (i.e., underused, overused, or misused), may provide … Continue Reading

OIG Calls for Improvements in Medicare Appeals Process

The OIG has issued a report entitled “Improvements Are Needed at the Administrative Law Judge Level of Medicare Appeals.” The report discusses the impact of regulatory and organizational changes that went into effect in 2005 that required Medicare administrative law judges (ALJ) to follow new regulations addressing how to apply Medicare policy, when to accept new … Continue Reading

OIG Reports Almost $7 Billion in Audit/Investigation Recoveries for FY 2012

On November 27, 2012, the HHS Office of Inspector General (OIG) released its fall Semiannual Report to Congress, which summarizes significant OIG enforcement, investigation, and audit activities for the period of April 1 – September 30, 2012, along with summary information for all of FY 2012. Most notably, the OIG reports approximately $6.9 billion in … Continue Reading

OIG Issues FY 2013 Work Plan

The HHS Office of Inspector General (OIG) has released its FY 2013 Work Plan, which outlines audit, inspection, and investigative initiatives that the OIG intends to conduct in the coming year. The OIG plans activities in a wide range of areas, including reviews of Medicare fee-for-service reimbursement and program integrity policies involving virtually all types … Continue Reading

Adjustment to the 2013 Amount in Controversy Thresholds for Medicare Appeals

CMS has published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The calendar year 2013 AIC threshold amounts are $140 for ALJ hearings (up from $130 in 2012) and $1,400 for judicial review (compared to … Continue Reading

CMS Invites Comments on Preliminary Supervision Level Decisions for Selected Hospital Outpatient Services

The Centers for Medicare & Medicaid Services (CMS) is seeking comments on its preliminary decisions on supervision levels for select Medicare hospital outpatient services, based on recommendations of the Hospital Outpatient Payment Panel at its meeting in August 2012. CMS proposes accepting the Panel’s recommendations that 15 services be changed from direct supervision to general … Continue Reading

CMS Releases Medicare Beneficiary Ombudsman Report

CMS has released its 2011 Ombudsman Report to Congress, which describes the activities of the Office of the Medicare Ombudsman (OMO) and sets forth the OMO’s recommendations for improving beneficiaries’ experiences with Medicare. Specific recommendations to CMS cover three topics: (1) recovery of conditional payments from beneficiaries by the Medicare Secondary Payer Recovery Contractor; (2) … Continue Reading

GAO Reviews Medicare Special Needs Plans for Dual-Eligible Beneficiaries

The Government Accountability Office (GAO) has issued a report entitled “Medicare Special Needs Plans: CMS Should Improve Information Available about Dual-Eligible Plans’ Performance.” The report examines the characteristics of dual-eligible beneficiaries enrolled in Medicare Advantage plans known as dual-eligible special needs plans (D-SNPs), which serve Medicare beneficiaries who also are eligible for Medicaid because they … Continue Reading

Preliminary 2013 Medicare Clinical Laboratory Fee Schedule Determinations

CMS has posted its new and reconsidered Medicare clinical laboratory fee schedule (CLFS) codes and preliminary payment determinations for calendar year 2013. Notably, it is CMS’s preliminary determination to set payment for those new Tier 1 and Tier 2 molecular pathology procedures codes reimbursed under the CLFS using the gap-fill mechanism rather than through cross-walking … Continue Reading

CMS Open Door Forum on Manual Medical Review of Therapy Claims (Sept. 5)

On September 5, 2012, CMS is hosting a Special Open Door Forum (ODF) on Manual Medical Review of Therapy Claims. The call will provide an opportunity for providers to ask questions about the documentation requirements associated with the mandated manual medical review of therapy services from October 1-December 31, 2012 that was enacted by the … Continue Reading