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As President Obama and Congress consider healthcare reform, they examine ways to reduce costs yet retain quality care.
Discussions have increased around facilities such as the Mayo Clinic in Rochester, MN, according to HealthLeaders Media. The Mayo Clinic is able to provide high quality care for less than the cost of care in other parts of the country, where the quality may be lower.
Is this because of overutilization? Are physicians increasing costs by ordering too many tests? If this is the case, then experts say that it could be time to change the way physicians are reimbursed. However, the details of this change are still unclear.
Source: HealthLeaders Media
May 4-11 Issuances: OIG releases reports, CMS proposes decision memo, and more
OIG issues review of oxaliplatin billing at Providence Alaska Medical Center
On May 8, the OIG issued a review of oxaliplatin billing at Providence Alaska Medical Center for calendar year 2005. The OIG found that Providence Alaska billed Medicare for an incorrect number of service units for one oxaliplatin outpatient claim and received an overpayment of approximately $31,000.
OIG issues review of separately billed lab tests paid by National Government Services, Inc., for ESRD beneficiaries
On May 6, the OIG released a review of separately billed lab tests paid by National Government Services (NGS), a Medicare fiscal intermediary, for laboratory tests that dialysis facilities provided to end-stage renal disease (ESRD) beneficiaries. The OIG estimated that NGS overpaid dialysis facilities $3.9 million for laboratory tests provided to ESRD beneficiaries during calendar years 2004-2006.
CMS issues proposed decision memo for pharmacogenomic testing to predict warfarin response
On May 6, CMS published a proposed decision memo in which it proposed that pharmacogenomic testing to predict warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin and only then in the context of a prospective, randomized, controlled clinical study when that study meets certain standards.
View the proposed decision memo.
Frequently asked questions
Last week, CMS released several new/updated frequently asked questions (FAQ) last week related to Medicare fee-for-service payment, coding, and billing.
CMS Issues Instructions for Recoupment of Overpayments related to MS-DRG 956
On May 8, CMS issued instructions on the mass adjustment of claims for MS-DRG 956 (Limb Reattachment, Hip & Femur Proc. For Multiple Significant Trauma). The Inpatient Pricer had mistakenly identified this DRG as a “special-pay” post acute care transfer DRG. Payment under the “special-pay” methodology resulted in overpayments for discharges that met the criteria for the post acute care transfer rule. The mass adjustments must be completed by August 1, 2009.
Effective date: October 1, 2008
Implementation date: April 27, 2009
CMS implements Section 148 of MIPPA regarding outpatient status for a CAH
On May 8, CMS issued a transmittal providing billing instructions based on the new criteria for determining a patient’s outpatient status for a critical access hospital (CAH) or an entity provider-based to the CAH, per Section 148 of the Medicare Improvements for Patients and Providers Act of 2008.
Effective date: July 1, 2009
Implementation date: July 6, 2009
CMS clarifies requirement for podiatric treatment
On May 8, CMS issued a transmittal clarifying the requirement for podiatric treatment in Pub. 100-04, Ch. 32, § 80.8. This clarification is necessary to support podiatric coverage requirements found in Pub. 100-02, Ch. 15, § 290.
Effective date: June 8, 2009
Implementation date: June 8, 2009
CMS releases MLN Matters articles
CMS released two MLN Matters article related to a transmittal previously outlined in Medicare Weekly Update.
- Ensuring Only Clinical Trial Services Receive Fee-For-Service Payment on Claims Billed for Managed Care Beneficiaries
- Surgery for Diabetes National Coverage Determination (NCD)
CMS also released a special edition MLN Matters article.
April 6-13 Issuances: OIG issues reviews of high-dollar claims, CMS updates FAQs
OIG reviews high-dollar payments for Medicare outpatient claims processed by TriSpan for the period January 1 through December 31, 2004
On April 9, the OIG released a review of high-dollar payments for Medicare outpatient claims processed in 2004 by TriSpan Health Services, a Medicare fiscal intermediary. Of the 16 payments of $50,000 or more that TriSpan made to providers for outpatient services during 2004, the OIG found that only one was appropriate. TriSpan overpaid two providers $767,000 on 15 claims.
OIG reviews of high-dollar payments for inpatient services processed by NGS in certain states for calendar years 2004 through 2006
On April 6, the OIG released a review of high-dollar payments for inpatient services processed from 2004–2006 by National Government Services (NGS), a Medicare fiscal intermediary, in Illinois, Indiana, Kentucky, and Ohio. The OIG found that of the 303 high-dollar payments NGS made to hospitals for inpatient services during these years, 39 were appropriate. The remaining 264 payments included net overpayments totaling $7.4 million.
Frequently asked questions
CMS released several new/updated frequently asked (FAQ) questions last week related to Medicare fee-for-service payment.
CMS posts final decision memo for positron emission tomography for solid tumors
On April 3, CMS posted a final decision memo in which it announced revisions to Section 220.6 of the Medicare NCD Manual to reflect a new framework for most solid tumor oncologic indications and for myeloma. CMS is adopting a coverage framework that replaces the four-part diagnosis, staging, restaging and monitoring response to treatment categories with a two-part framework that differentiates FDG PET imaging used to inform the initial antitumor treatment strategy from other uses related to guiding subsequent antitumor treatment strategies after the completion of initial treatment.
Frequently asked questions
CMS posted several new/updated frequently asked questions (FAQ) related to coding and Medicare fee-for-service payment.
February 16-23 Issuances: CMS updates FAQs, OIG releases audit reports, and more
CMS released several updated frequently asked questions (FAQ) last week, related to Medicare fee-for-service payment and coding.
View the fee-for-service FAQs.
OIG releases review of outpatient claims processed by TriSpan Health Services for CY 2006
On February 17, the OIG issued a report on outpatient claims processed by TriSpan Health Services during 2006. The OIG found that TriSpan underpaid one provider $13,856 during that time.
OIG reviews oxaliplatin billing at San Jacinto Methodist Hospital for CYs 2004 and 2005
On February 18, the OIG issued a report on oxaliplatin billing at San Jacinto Methodist Hospital for CYs 2004 and 2005. During that time, the OIG found, San Jacinto billed for 10 times the number of units of oxaliplatin that were actually administered and received overpayments totaling $104,106 for the three outpatient claims that the OIG reviewed.
CMS instructs contractors to strengthen program safeguards for facet joint injection services
On February 6, CMS issued a transmittal instructing its contractors to strengthen safeguards against improper payment of claims for facet joint injection services. The instructions follow an OIG audit finding that 63% of facet joint injection services allowed in 2006 did not meet Medicare program requirements.
Effective date: March 9, 2009
Implementation date: March 9, 2009
CMS announces change to amount in controversy requirement for administrative law judge (ALJ) hearings and Federal District Court appeals
On January 30, CMS issued a transmittal notifying its contractors of a change to the amount in controversy requirement for ALJ hearings and appeals in Federal District Court.
Effective date: March 4, 2009
Implementation date: March 4, 2009
View a related MLN Matters article.
CMS issues transmittal on payment for co-surgeons in a method II critical access hospital (CAH)
On January 30, CMS released a transmittal to implement several changes to the way contractors issue payment for co-surgeons when a CAH is involved.
Effective date: January 1, 2008
Implementation date: July 6, 2009
View a related MLN Matters article.
MLN Matters articles
CMS released the following MLN Matters article related to an item previously covered in Medicare Weekly Update.
CMS also released the following special edition MLN Matters article.
Frequently asked questions
On January 23, CMS issued new/updated frequently asked questions (FAQ) related to Medicare fee-for-service payment. CMS also issued FAQs related to the Correct Coding Initiative edits.
View the fee-for-service FAQs.
View the Correct Coding Initiative FAQs.
OIG reviews high-dollar payments for Medicare outpatient services processed by Pinnacle Business Solutions, Inc., during calendar year 2005
On January 16, the OIG issued a report on high-dollar payments processed by Pinnacle Business Solutions, Inc., a fiscal intermediary, for Medicare outpatient claims in 2005. The OIG found that all four of the high-dollar payments Pinnacle made during that period were inappropriate.
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