The recovery audit contractor (“RAC”) for Region B covering the Midwestern states, CGI Federal, Inc., is requesting additional documentation from providers regarding facet joint injections without reported imaging guidance (CPT codes 64470-64476). The requests for additional documentation acknowledge that CMS has not yet approved this issue for complex review and further acknowledge that the RAC […]
During the Recovery Audit Contractor (“RAC”) demonstration program, a significant number of the claims denied were denied for the reason that an inpatient hospital admission was not medically necessary. The RACs regularly based these denials not upon published Medicare guidance, but based upon the criteria of private companies, such as InterQual. In an effort to […]
The American Hospital Association (AHA) expressed its concerns with numerous regulations adversely impacting hospitals, by way of letter dated January 14, 2010 to Darrell Issa, the Chairman of the Committee on Oversight and Government Reform in the U.S. House of Representatives. Among numerous other regulations causing strife for hospital providers (e.g., the Federal Stark law, […]
Following The HLP’s submission of numerous written inquiries and phone calls to representatives of CMS, National Government Services, Inc. (“NGS”) (the Medicare Affiliated Contractor), and CGI (the Medicare RAC for Region B), on November 8, 2010, CMS published a response to Frequently Asked Questions related to RAC reviews of Periodic Interim Payments (“PIP”). As described […]
On November 10, 2010, the Centers for Medicare & Medicaid Services (“CMS”) published its much-anticipated Proposed Rule regarding the Medicaid Recovery Audit Contractor (“RAC”) program. Section 6411 of the Patient Protection and Affordable Care Act (“Affordable Care Act”) requires each State to establish a Medicaid RAC program similar to the existing Medicare RAC program. States […]
With respect to the Medicare appeals process, the OIG plans to review and examine the following: • The timeliness of the Medicare contractors’ determinations on requests for reconsideration at the first level of Medicare appeals as they have 60 days to conclude a redetermination pertaining to a denied claim. • The characteristics of cases brought […]
On October 4, 2010, the OIG released its Work Plan for the FY of 2011. Throughout the week, we will be posting on various aspects of the Work Plan pertinent to our clients and our readers in the following areas: • Hospitals • Home Health Agencies • Hospices • Evaluation and Management Services • Imaging […]
CMS has issued new guidance expanding on the Fee-for-Service Reimbursement instructions detailed in CR 6960 (which HLP had blogged about here). The earlier change request explained the basic standards stemming from the Section 6404 of the Patient Protection and Affordable Care Act of 2010: services billed more than one year after they were provided would […]
As HLP reported, in April, CMS requested that the RAC for Region D remove an anesthesia care package it had posted to its website. Now, the issue has been re-posted, with some changes: Under NCCI Edit rules, the anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia […]
Hospice providers are facing ongoing claims scrutiny, highlighting the importance of compliance. On June 8, 2010, the Centers for Medicare and Medicaid Services (“CMS”) held a national outreach session to educate hospice providers regarding specific vulnerabilities involving hospice services, with specific emphasis on the provision of hospice services to beneficiaries residing in nursing facilities. Two […]
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