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More than a year after several rounds of review on proposed revisions to existing Advance Beneficiary Notice (ABN) Forms ABN-G and ABN-L, CMS published revised Form CMS-R-131.
As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:
- The services fail to meet Medicare’s medical necessity guidelines
- The services are screening services that are provided more frequently than Medicare provides a benefit for
- The services are custodial in nature
In order to be effective, such notice must occur prior to the performance of these services. This protects beneficiaries from unexpected financial liability. The provisions in Medicare law that require such protections are referred to as the “limitation on liability” provisions. Noncoverage most commonly arises with respect to diagnostic services (lab tests, imaging services, etc.). In such cases, the diagnostic information on the physician order does not support the medical necessity of the services ordered.
According to CMS’ annual report released October 17, Medicaid spending is expected to significantly surpass the growth rate of the U.S. economy over the next 10 years,
HealthImaging reports.
The report, presented at the fall meeting of the National Association of State Budget Officers, predicts that Medicaid benefits spending will rise 7.3% from 2007, reaching $339 billion in 2008, and increasing annually at an average rate of 7.9% over the next decade, to $674 billion in 2017. The expected growth rate of the overall economy is 4.8%.
Click here to read the full HealthImaging report.
A new survey reveals that most doctors are inadequately prepared to counsel patients on the newer, consumer-directed health plans, Forbes reports.
The plans, which are designed to put more responsibility for healthcare decisions on the individual patient, often include health savings accounts and have high deductibles.
But 43% of doctors said they have heard very little about these consumer-directed plans, and less than 48% believe they are prepared to address financial matters with their patients.
“I think as these plans roll out, it’s really important to educate doctors about (them) and about some of the differences between these plans and more traditional models of insurance,” said study co-author Dr. Craig Pollack, as reported in Forbes.
A new medical specialty that focuses on meeting the needs of seriously ill patients may save the average U.S. community hospital up to $1.3 million per year, researchers said this week, according to a Reuters report.
The palliative care teams, usually consisting of a doctor, nurse and social worker, can help reduce hospitals’ costs from lengthy intensive care stays or unnecessary tests by guiding patients and their families to make more informed decisions and rely on resources available to them.
Special care teams focus on the sickest 5-10% of patients with the most difficult cases. Many of these patients also have Medicare coverage, so hospitals often lose money on them because they are paid only a set fee per admission.
Americans are not getting any richer. And hospitals continue to realize it.
Kay Wagner, the director of patient access at St. Vincent Healthcare in Billings, MT, said fewer people are able to make payments at her facility.
"They have fewer dollars in the bank for emergencies," Wagner told the Billings Gazette. "People used to come in and say, ‘I can pay this off in a year’ or ‘I can pay you $50 a month.’ They can’t do it anymore."
To read the full story in the
Billings Gazette,
click here.
An analysis of Justice Department records shows that private citizens assisted authorities in recouping at least $9.3 billion from healthcare providers accused of fraudulent activity, Yahoo News reports.
The Justice Department increased efforts in the 1990s to fight healthcare fraud by relying on private citizens with inside knowledge. Whistle-blowers are now credited with more than 90% of the department’s healthcare fraud lawsuits.
Question: What services are included in CPT code 99291 (critical care, first 30-74 minutes) and should therefore not be billed separately?
Answer: Hospitals must follow the CPT instructions related to CPT code 99291. Any services that CPT indicates are included in the reporting of CPT code 99291 should not be billed separately by the hospital.
Source: Centers for Medicare & Medicaid Services
Question: Who is responsible for billing for emergency department services when the patient is discharged from an Inpatient Psychiatric Facility (IPF) to the emergency room and returns to the IPF within the same day?
Answer: The status of discharge is what determines payment responsibility. Decisions regarding appropriate site of care for Inpatient Psychiatric Facility (IPF) admissions and discharges are made by the attending physician. First, the patient should not be discharged from the IPF when there is a reasonable level of expectation that the patient will return to the IPF within the same day. Nevertheless, if a patient is discharged, any subsequent services they receive are billed by the provider of those services, whether it is an Emergency Room (ER), hospital, etc. If the patient had never been officially discharged from the IPF, the IPF would be responsible for all of the patient’s subsequent charges. While the person is an inpatient of the IPF, the IPF must furnish all necessary covered services to a Medicare beneficiary. Therefore, if the patient has not been discharged, the cost of the ED services is the responsibility of the IPF. See § 412.404(d)(3).
Source: Centers for Medicare & Medicaid Services
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