This week’s Medicare updates include the quarterly listing of program issuances, a fact sheet on the federal health exchange’s 2018 open enrollment period, revised instructions for certificate of medical necessity and durable medical equipment information forms, and more!
The largest source of estimated revenue loss in the healthcare midcycle in 2016 was attributed to inadequate documentation, according to a report by the Advisory Board. The report analyzed a range of hospitals in varying size, from 0–500 beds, to determine the impact of midcycle functions. The revenue loss reported for an average 250-bed hospital was $2–$5.5 million.
Mastering hierarchical condition categories (HCC) is key to success under new reimbursement methodologies that rely on risk-adjustment, quality, and value metrics such as the Quality Payment Program (QPP). Organizations need to take a close look at their training and audit programs to ensure that valuable information isn’t being left out of documentation—and negatively impacting HCC scores.
Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA) added a requirement that will dramatically revise the Medicare Clinical Laboratory Fee Schedule (CLFS) effective January 1, 2018.
In July, Utah pain doctor Jahan Imani, MD, and Intermountain Medical Management, P.C., entered into a nearly $400,000 settlement with the OIG to resolve allegations that Imani’s practice submitted false or fraudulent claims due to improper modifier use for payment by improperly using modifier -59 with HCPCS code G0431.
Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
