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August 1

CMS Imposes Limit to Look-Back Period for Two-Midnight Reviews

CMS has announced that it has clarified the instructions for medical review of claims affected by the temporary suspension of the BFCC-QIO claim audits under the two-midnight inpatient admissions rule.   Specifically, CMS announced that these reviews will be limited to a six-month look-back period from the date of admission.  Per CMS, Medicare Fee-For-Service (FFS) claims […] Read More

June 14

CMS Posts Draft Medicare Outpatient Observation Notice (MOON), Instructions, and a Supporting Statement

CMS has posted the draft Medicare Outpatient Observation Notice (MOON), Instructions, and a Supporting Statement.  The Medicare Outpatient Observation Notice (MOON) is a standardized notice developed to inform beneficiaries (including Medicare health plan enrollees) that they are an outpatient receiving observation services and are not an inpatient of the hospital or critical access hospital (CAH).  […] Read More

June 13

GAO Study Concludes that Opportunities Remain to Improve Medicare Appeals Process

In a report requested by the Senate Finance Committee, the Government Accountability Office (GAO) has determined that opportunities still remain for HHS to improve the Medicare fee-for-service appeals process and to reduce the increased volume of appeals.  The GAO study concludes that (1) Absent more complete and consistent appeals data, HHS’s ability to monitor emerging […] Read More

June 9

CMS Policy Change Delay: Required Use of JW Modifier for Discarded Part B Drugs and Biologicals

CMS announced in the June 6th Hospital Open Door Forum call that the policy change announced in April, requiring the use of the JW modifier for discarded Part B drugs and biologicals, will be delayed to January 1, 2017.  Per the policy change, when processing claims for drugs and biologicals (except those provided under the Competitive Acquisition Program […] Read More

June 9

QIOs to Re-Review All Denied Short-Stay Patient Status Claims

According to a CMS spokesperson, the temporary pause in short-stay status reviews that began on May 4, 2016 may stretch through the end of July. That information, along with the announcement that the BFCC-QIOs will re-review all short stay patient status claims that were denied under the QIO medical review process came during the June […] Read More

February 10

Appeals Court Rules in Favor of Providers on Medicare Claims Appeal Backlog

In an opinion issued on February 9th, the U.S. Court of Appeals for the District of Columbia Circuit reversed a lower court’s dismissal of the lawsuit filed by the American Hospital Association (AHA) and a group of hospitals that seeks to compel the U.S. Department of Health and Human Services (HHS) to meet its mandated deadlines […] Read More

January 29

Cigna Banned From Selling New Medicare Advantage Plans

In a January 21, 2016 letter to Cigna Corporation (“Cigna”) the Centers for Medicare & Medicaid Services (“CMS”) announced its determination and intent to impose intermediate sanctions suspending the enrollment of and marketing to new customers of all Cigna Medicare Advantage and Standalone Prescription Drug Plan Contracts.  The sanctions, which became effective at 11:59 p.m. […] Read More

July 27

“Grace Period” Coverage Under Exchange Plans: How Federal Regulations Can Alter Eligibility Determinations for Providers

By Matthew Horton, Washington & West, LLC The Affordable Care Act (ACA, or commonly referred to as Obamacare) altered the landscape for individual and small group insurance plans. ACA altered this market with two important provisions: (1) the creation of Qualified Health Plans (QHPs, also referred to as Exchange Plans) and (2) establishing Exchanges (also […] Read More

July 20

CMS Issues Unified Program Integrity Contract (UPIC) RFP

On July 17, 2015 the Centers for Medicare and Medicaid Services (CMS) published the RFP for services under the Unified Program Integrity Contract (UPIC). Responses to the RFP are due by August 18th at 12:00 pm (EST). Read More

July 16

BREAKING: Supreme Court Upholds Subsidies

The Supreme Court ruling in King v. Burwell (11-114) upholds the Federal tax subsides of the Patient Protection and Affordable Care Act.  As per the Court’s ruling: “Petitioners’ plain-meaning arguments are strong, but the Act’s context and structure compel the conclusion that Section 36B allows tax credits for insurance purchased on any Exchange created under […] Read More

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