On June 17, 2011, the Centers for Medicare & Medicaid Services (“CMS”) announced that beginning July 1, 2011 it will start to utilize an innovative predictive modeling technology to aid the prevention of Medicare fraud. This CMS announcement comes in the wake of Obama’s Campaign to Cut Waste launch. The…
MedPAC released its highly anticipated proposal calling for a reduction in the use of imaging services, including MRIs, CT scans and nuclear medicine, and, in particular, recommended pre-authorization for medical imaging services as a means to accomplish this objective. The MedPAC report focuses, in particular, on physicians who order an…
In reviewing certain inpatient hospital claims, the RAC for Region B (covering the Midwestern states), CGI, and its subcontractor, PRG Schultz, are now requesting that nursing notes not be included in response to additional documentation requests (“ADRs”). Note that this directive is not consistent across all ADRs, as other ADRs…
In addition to the multitude of auditing activities and programs that exist, the Medicare Carriers/Medicare Administrative Contractors also conduct medical reviews. Like many other auditing programs, these probe reviews are data driven and are conducted for the purpose of validating potential provider billing errors. The process may include either provider…
The Centers for Medicare & Medicaid Services (“CMS”) is taking steps in anticipation of its Medicare Part D RAC program release; this component of the RAC program is expected to begin in the third quarter of 2011. The director of the Medicare Program Integrity Group, John Spiegel, announced that CMS…
The Centers for Medicare & Medicaid Services (“CMS”) released the latest edition of its Medicare Compliance Newsletter. The publication contains examples of Medicare billing errors and guidance on how to avoid such mistakes. The newsletter may be viewed here. For more information regarding compliance or for assistance defending an audit,…
The Centers for Medicare and Medicaid Services (“CMS”) overpayment recovery through its Recovery Audit Contractor (“RAC”) program is on the rise. CMS recovered in excess of $313 million in Medicare overpayments since October 2009, and almost half of that amount ($162 million) was collected during the first three months of…
Our attorneys are seeing an increase in Medicare claim denials resulting from the lack of valid practitioner signatures. A new publication from the Medicare Learning Network® titled “Comprehensive Error Rate Testing (CERT) Signature Requirements” provides the guidance necessary to avoid such denials. The fact sheet aims to educate health care…
The Medicare Recovery Audit Contractors (RACs) are introducing another weapon in their artillery: semi-automated claims review. Although semi-automated claims review is not specifically authorized by the RAC Statement of Work, the method is essentially a combination of an automated claims review and a complex claims review. CMS describes a semi-automated…
Wisconsin Physician Services (“WPS”), the Medicare Part B Carrier for providers in Michigan, Illinois, Minnesota and Wisconsin, recently conducted a service-specific probe review of Current Procedural Terminology (“CPT”) 99233 billed by neurology providers. WPS found that only 4 percent of billed claims were payable. 96 percent were denied or down-coded.…