Search Results for: medicare suspension

Medicare, Medicaid and CHIP Enrollment Revocation and Denial Authorities Have Expanded.  What Steps are You Taking to Reduce Your Level of Risk?

Big Changes to CMS Form 855 are on the Horizon[/caption] (September 18, 2019): On September 10, 2019, the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) published a Final Rule in the Federal Register entitled, “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider […]

Medicare, Medicaid and CHIP Enrollment Revocation and Denial Authorities Have Expanded.  What Steps are You Taking to Reduce Your Level of Risk? Read More »

UPIC Dental Audits (Such as Qlarant Dental Audits) Have Been Initiated. Is Your Practice Ready for its Medicare Dental Claims or Medicaid Dental Claims to be Audited?

(July 3, 2018): While a number of Medicare Advantage Plans now offer supplemental coverage for preventive, basic, and major dental services, only a narrow category of dental services qualify for coverage and payment under standard Medicare Part A (pursuant to Section 1862(a)(12) of the Social Security Act). Presently, only qualifying Medicaid beneficiaries are likely to

UPIC Dental Audits (Such as Qlarant Dental Audits) Have Been Initiated. Is Your Practice Ready for its Medicare Dental Claims or Medicaid Dental Claims to be Audited? Read More »

ZPIC Audits / UPIC Audits: The Impact of Transmittal 768 on the Medicare Appeals Process Timeline

(April 12, 2018): A big concern with the Medicare appeals process is the ghastly backlog at the Office of Medicare Hearings and Appeals (OMHA) for an Administrative Law Judge (ALJ) hearing coupled with the government’s authority to recoup alleged overpayments after the second level of appeal (reconsideration). There is renewed buzz regarding the backlog and

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The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?

(April 2, 2018): Our nation’s demographics are changing.  In less than 20 years, it is estimated that for the first time in country’s history, the number of individuals over the age of 65 will exceed the number of children.[1] These increases are already being seen in our rapidly expanding Medicare healthcare benefit program.  At last

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Medicare’s Home Health Probe and Educate Program is Underway

(December 4, 2015): The Centers for Medicare and Medicaid Services (CMS) has directed its contractors to initiate a home health probe and educate program review process with home health agencies around the country. The focus of this program will be to assess agencies’ compliance with the new face-to-face (F2F) documentation requirements that became effective 01/01/15.

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OIG Finds Significant Medicare Dental Overpayments Made to Hospitals

(October 27, 2015): Late this summer, the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) announced that more than $2 million in payments to dental providers for hospital outpatient dental services would have to be reimbursed to the federal government for failure to comply with Medicare program requirements. The

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Medicare Ophthalmology Audits: Is Your Practice Ready?

(October 26, 2015): Last month, the Department of Health and Human Services (HHS), Office of Inspector General (OIG) released a study entitled “Questionable Billing for Medicare Ophthalmology Services.” As the study findings reflect, the OIG concluded that for the year 2012, approximately $171 million of the Medicare payments made that year for ophthalmology services were

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ZPIC Use of the Medicare Fraud Prevention System

(October 20, 2015): As required by the Small Business Jobs Act of 2010, the Department of Health and Human Services (HHS) is required to conduct a review of payments for Medicare fee-for-service claims by using “predictive analytics technologies” every three years. Predictive analytics technologies employ a variety of predictive models and statistical analysts for detection

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The Medicare Appeals Process is Broken

(May 5, 2015): As the health care providers and suppliers we represent can easily attest, there are serious problems plaguing the current Medicare appeals process. Rubber-stamp denials by contractors[1] at lower levels of appeal, the failure of Medicare contractors to apply the correct coverage rules and requirements when assessing a claim, and lengthy delays in

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Individual Liability for Medicare Overpayment Claims

(February 24, 2015): Medicare recently finalized regulations allowing enrollment as a Medicare provider to be denied if any owner or control person of the enrolling provider is affiliated with another provider which owes money to Medicare. These regulations are based on sections of the 2010 Affordable Care Act (ACA). They provide CMS an indirect means

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