Archive for the ‘Compliance’ Category

The Associated Press reports that for three years, the Centers for Medicare & Medicaid Services (CMS) repeatedly ignored internal watchdog warnings about swindlers stealing millions of dollars by scamming several programs, documents show. CMS received roughly 30 warnings from inspectors over three years during the Bush and Obama administrations but didn’t respond to half of them, even after repeated letters, according to records provided to The Associated Press by U.S. Sen. Charles Grassley’s office.

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Confused about the Evaluation and Management Consultation codes in CPT® 2010 (99241-99255)?  Didn’t Medicare just say that, save for HCPCS Level II codes for telehealth consultation, they were out the window? (See “2010 MPFS Final Rule Still Holds Surprises,” EdgeBlast No. 136.) So why are they in the official CPT® code book? Is it a mistake, and if not, does that mean commercial payers are reimbursing for them?

It’s no mistake, says Sheri Bernard, CPC, CPC-H, CPC-P, vice president, clinical coding communications, AAPC. “The codes remain in CPT® 2010 with expanded official guidelines that iden­tify scenarios that in the past would not have been consid­ered consultations,” according to Bernard. 

Check with payers to whom you report these codes to find out if they are reimbursing them and for what services specifically. Unfortunately, at this point no one really knows what all the payers will think of these codes now.

AAPC former NAB member Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, is asking colleagues to contact her with what payers in their states say they will accept come Jan. 1, 2010. She will compile the data into a spreadsheet and make it available via the AAPC Web site.

If you’d like to contribute information to this project, and help Cobuzzi clear the confusion with her grass-roots project, send what you’ve learned about payers in your area to her in an e-mail (b.cobuzzi@att.net).

Recovery Audit Contractors (RAC) HealthDataInsights (HDI) and CGI Federal have added to their list of new issues eligible for review as per the Centers for Medicare & Medicaid Services (CMS).

The RAC program, mandated by the Tax Relief and Health Care Act of 2006, is being implemented in 2010 to detect and correct past improper Medicare payments.

Tip: Don’t wait until Jan. 1, 2010 to review these new issues and correct any problems your outpatient hospital or physician practice may uncover. Read more »

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added new mandatory reporting requirements for group health plans (GHP) and non-group health plans (NGHP), such as liability insurance (including self-insurance), no-fault insurance, and workers’ compensation.

The implementation dates for most casualty insurers have come and gone, but there’s still time for compliance.

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The Federal Trade Commission’s (FTC) compliance deadline for creditors and financial institutions to develop and implement an identity theft prevention program under the Red Flags Rule was delayed—yet again. The implementation date originally set for Nov. 1, 2008 has been delayed three times to 2009 dates: May 1, Aug. 1, and Nov. 1. At the request of Congress members, the latest implementation date now extends to June 1, 2010.

There has been question as to how the Red Flags Rule applies to health care providers. According to the FTC’s Fighting Fraud with the Red Flags Rule: A How-To Guide for Business, page 9-10, “The definition of ‘creditor’ is broad and includes businesses or organizations that regularly defer payment for goods or services or provide goods or services and bill customers later. Utility companies, health care providers, and telecommunications companies are among the entities that may fall within this definition, depending on how and when they collect payment for their services.”

To help determine if you should comply under the Red Flags Rule, the FTC offers resources on their Web site. The FTC’s resources also include an FTC compliance template and information on how to design and implement an identity theft prevention program. The American Medical Association (AMA) also has prepared a sample policy template for providers.

For excellent coverage on the Red Flags Rule, read pages 18-19 in the February 2009 issue of Coding Edge.

Carriers and Part A and Part B Medicare Administrative Contractors (A/B MACs) are creating lists and checking them twice, but they’re not looking for who’s been naughty or nice. On these lists are X-ray suppliers currently billing Medicare who are not in the Provider Enrollment, Chain, and Ownership System (PECOS). Read more »

Physicians, non-physician practioners (NPPs), and other Part B providers and suppliers submitting claims to carriers or Part B Medicare Administrative Contractors (B/MACs) for ordered or referred items or services can expect further scrutiny during the claims editing process.

Beginning Oct. 5, carriers and B/MACs expanded claims editing to include validation of the ordering/referring provider’s national provider identifier (NPI) and name reported on the claim against Medicare’s provider enrollment records. Read more »

A laptop computer that held a file containing information on every physician in the country contracted with a BlueCross BlueShield-affiliated insurance plan was stolen out of a BCBS employee’s car Aug. 27, creating a possible data breach concern. Read more »

The American Medical Association (AMA) posted several Category II code updates in recent weeks. The latest additions, deletions and revisions will affect how physicians report certain conditions in 2010, but you won’t find them listed in the CPT^® books until 2011. Read more »

Computer hardware giant Dell has joined the fray of electronic health record (EHR) vendors. The Round Rock, Texas-based company announced Sept. 10 its new Affiliated Physician EMR Solution. Read more »