Tag Archives: CMS

Ever Wanted To Know How Long Medicare Has To Recoup Medicare Onerpayments

Healthcare providers who participate in Medicare are sometimes surprised when the government later decides that an overpayment was made. As a healthcare Law firm provider who accepts federally funded reimbursement, you may wonder how long the government has to make a claim against you for alleged overpayments.

For Medicare overpayment, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment. This statute of limitations begins to run from the date the reimbursement payment was made, not the date the service was actually performed. CMS has instructed carriers not to recover payments that have not been reopened (where no attempts have previously been made to collect) within 4 years from the date of payment, unless the case involves fraud or similar fault. CMS instructs carriers not to recover overpayments discovered later than 3 full calendar years after the year of payment, unless there is evidence that the physician or beneficiary was at fault with respect to the overpayment. Liability of the physician for refunding an overpayment is based on fault- if the overpayment was a result of a lack of disclosure or information from the Medicare beneficiary, the liability may shift to the beneficiary. See Medicare Carrier Manual 7100.

Florida Healthcare providers should be aware that the 3 year statute of limitations does not apply to recovering over payments made as result of false pretenses or fraud. In bringing a civil action against an alleged perpetrator of fraud for civil penalties, the Federal False Claims Act grants the government and qui tam whistle blowers either (i) 6 years from the date of violation or (ii) 3 years from the date the facts material to the right of action are known or reasonably should have been known by the government, but not to exceed 10 years from the date of violation . When a “violation” has occurred is arguable. The statute of limitations under the Federal False Claims Act could potentially start to toll on the date the false claim is submitted, but the government has argued that the statute of limitations does not toll until the date of payment on the claim by the government or even final settlement on a cost report with the government. Also important to note is that failure to promptly refund a reimbursement previously discovered by a healthcare provider has been construed as a violation of the Federal False Claims Act. In other words, if you discover an overpayment and wait for CMS to make an official refund request, you may still be subject to penalties and fines.

Furthermore, aside from civil monetary penalties, there are numerous criminal statutes under which the federal government could impose criminal penalties for health care fraud, including obstruction of a federal audit, mail fraud, conspiracy to defraud the government, RICO, the criminal false claims act, False Statements Act, the Social Security Act (wherein it is a felony to render any false statement or representation of material fact), federal anti-kickback statutes, and HIPAA.

Preparing Your Practice For The Medicare Rac Audits

Due to the success of the Recovery Audit Contractor (RAC) demonstration, CMS rolled out the Medicare RAC audits to all states in the year 2010 with the anticipation of recouping more monies and returning the improperly paid claims to the Medicare Trust Fund.

The program has been such a success that Medicaid has jumped on the band wagon and has mandated a similar program known as the Medicaid Integrity Contractor (MIC), which will be implemented in all 50 states by the year 2011

Now is the time to prepare for increased scrutiny of your claims by governmental agencies as its no longer a matter of will you be audited but when you will be audited.

The Department of Health and Human Services and Office of Inspector General provides a model formal compliance program to provide healthcare providers with guidance to on how to be compliant with CMS rules and regulations and to reduce a healthcare organizations risk exposure if they were subjected to an insurance audit. The seven elements of a model compliance program per the OIG are as follows:
Designation of a compliance officer and compliance committee
Development of compliance policies and procedures
Establishment of open lines of communication
Appropriate training and education
Internal monitoring and auditing of claims
Response and corrective action to detected deficiencies
Enforcement of disciplinary actions

In today’s health care environment most entities are already burdened with the everyday challenge of accurate billing and coding, compliant documentation, HIPAA regulations, physician managed care contracts, Stark laws, vendor contracts, and most importantly, patient service.

This leaves most health care entities with minimal resources to focus on compliance and audit risk issues.

With that being said, how does a healthcare organization, regardless of size, go about dealing with the increased burden of potential insurance audit scrutiny from both governmental and commercial payer?

The first step should be to perform an independent internal audit review of your organization’s documentation and compliance procedures. We know that during CMSs three year RAC Audit Demonstration Project, their findings indicated that somewhere between 70% – 75% of the overpayments identified were from coding errors and lack of documentation to support medical necessity. It would make sense that a healthcare organizations focus should be on ensuring that their providers are utilizing proper coding and supporting it with the correct documentation and that medical necessity is clearly documented for each patient encounter that supports the services rendered and billed.

To determine the accuracy of your providers coding and documentation and proper medical decision making, it is critical that your organization conduct on-going internal audits to determine any deficiencies that may exist within your organization. The review will help you identify deficiencies and allow you to correct them through proper education and training for your providers, which in turn will reduce your audit risk significantly if you are faced with an insurance audit. Implementing an education and training program based on your findings for your staff and medical providers is an absolute as you will notice that once implemented, your error rates due to coding and documentation deficiencies will drop significantly.

If such deficiencies are not identified and addressed by your organization, you may find Medicare or Medicaid knocking at your front door to inform you of your lack of compliance. At this point, the cost of disputing or paying for the findings of a governmental audit will far outweigh the cost of your organization identifying these issues first and putting a corrective action plan in place to fix them.

In terms of your internal review, there are many things to consider. Does your organization have the internal expertise to conduct proper audits and decide what areas to focus on? Will you base your efforts on the Medicare RAC findings which consist of validating that medical necessity is properly documented and that the coding that was billed is supported by proper documentation in the patient encounter notes? There are many variables that need to be pre-determined if your organization opts to do an internal audit review.

One thing every facility should think about that is considering conducting internal audits is that you must be confident that your audits are being performed by individuals who are “independent” of the documentation they are reviewing. It is also critical that your audit team have the appropriate skill set, credentials and clear understanding of the compliance rules and regulations per the Centers for Medicare and Medicaid Services (CMS) to be conducting the audits. If your organization lacks these resources, serious consideration should be given to hiring a third party audit firm that has the experience and credentials to assist your organization with the internal audit function. When selecting a vendor, make sure you are engaging a firm that has governmental audit experience and that they can identify any compliance deficiencies and more importantly, provide your personnel with the proper training and education to eliminate such deficiencies. The cost of utilizing a third party to assist your organization
will dramatically reduce your potential audit risk and your return on your investment will be tenfold compared to what the financial consequences could potentially be if you sit back and do nothing and let Medicare be the messenger.

Understanding Drupal As An Effective Healthcare Cms

Drupal CMS is open source software that can be easily leveraged to accommodate the needs of various corporations across the vast spectrum of public as well as private sectors. Since it is constantly updated by the Drupal community members, this CMS comes up with new innovations and Drupal consulting companies are constantly trying to increase Drupal adoption by creating meaningful web solutions to assists new stakeholders in new arenas. We all are aware of the fact that the health care industry is a booming and every growing sector and with changing lifestyles and increased work pressure, people are also becoming more prone to stress related health issues and have realised that taking better care of oneself is very important.

It is here when a website focusing specially on the healthcare industry takes the benefit of using Drupal CMS to remain competitive in the market. Drupal is one of the most favourite CMS of the web developers because of its easy to use and robust features built on an open source platform. Since it has an intuitive to use web installer, it makes the process of publishing content very easy. The healthcare industry is a specialized industry that contains a lot of technical jargons that is difficult to handle and can confuse the readers. So, it is important that a healthcare website or a healthcare related meaningful mobile solution is created in such a manner so that the content looks attractive and can easily be read. The user or the viewer should be attracted to the site so that they stay longer and browse the contents and give a look to it before they move out from the page.

How Drupal CMS Helps the Medical Industry

Attractive and interactive website: Medical websites usually contain lots of texts and less graphics so that the patients can derive proper information from the site. Reading and understanding of the medical terms are at times difficult to understand, so extensive pictures or any related videos can help the site and make it more interesting. Drupal CMS makes this possible with only few clicks.

Easy To Maintain And Manage: Drupal CMS makes the medical website very easy to manage and the content can be easily updated or edited according to the requirements. With easy plugins and tabs to operate the CMS, any person can change the content without even having the expertise in using Drupal.

Dynamic Website: PHP is used for programming and this is compatible with most of the operating system like Mac OS X, Linux. The CMS converts all the contents into PHP when you upload your content, thereby making it SEO friendly.

Dynamic Website: PHP is used for programming and this is compatible with most of the operating system like Mac OS X, Linux. The CMS converts all the contents into PHP when you upload your content, thereby making it SEO friendly.

Get your CCI edits right to avoid Medicare denials

The Correct Coding Initiative (CCI) edits are used by Medicare and other payors to bundle procedures that have been billed separately. These edits are one of the main causes behind Medicare denials. To further add to the woes, these edits are subject to revision on a quarterly basis. If you are not aware of the ever-changing CCI edits, you run the risk of claim denials, lost reimbursement, and potential recovery actions.ns.

More than 285,000 CCI edits are used by CMS to review claims for unbundling and correctable coding errors. The 2010 edition of Correct Coding Initiative (CCI) edits, version 16.0 is effective for claims filed on or after the first of January early next year. You can get all the updates in the Correct Coding Initiative (CCI) Edits manual, which you can get hold of in two ways. The first is through the CMS website, which contains a list of the CCI edits, by specific CPT sections. You can also obtain the CCI edits manual by purchasing the manual or sections of the manual from the NTIS website.

Apart from these, there are other one-stop coding websites which makes it easy for you to determine if any two CPT/HCPCS codes may be billed together, with or without a modifier. You can turn to such websites for all active NCCI Column 1 and Column 2 CPT/HCPCS codes with symbols clarifying modifier usage, extensive coverage of general and CPT section specific coding rules, among a host of other tips and tricks of the trade.

All you need to do is sign up for one and unravel the treasure trove of medical coding know how that it has on offer.

We provide you simple, instant connection to official code descriptors & guidelines and other tools for CEU Seminars, correct coding initiativethat help coders and billers to excel in the work they do every day.

CMS MLN helps you keep pace with the latest Medicare policy changes

Medicare providers often find themselves in the dock when it comes to keeping pace with the latest changes in Medicare policy. This is especially true since the new Medicare Modernization Act came into being, which is one of the most important changes affecting the Medicare program.am.

One place where you can have access to all educational information for Medicare-fee-for-service providers is the Medical Learning Network (MLN) which is located in the Centers for Medicare & Medicaid Services (CMS) Website.

What’s MLN?

Medical Learning Network (MLN) is the name for the official CMS national provider education products crafted to promote national consistency of Medicare provider information.

The CMS learning network provides Medicare policy in simple language and shows you how you’re affected. The network also makes easy the process of finding answers and solving problems pertaining to Medicare.

It provides a variety of training and educational materials that break down Medicare policy into plain language with actionable tips to utilize in your day-to-day work. To deliver educational and updated programs, the network makes use of the Internet, brochures, videos and web-based training courses. Also, if you’re looking for articles on the new changes in Medicare policies, CMS learning network is just the right place to head to. Here you can have access to nationally-consistent MLN articles.

The CMS Medicare Learning Network plays a vital role in furthering the agency’s culture of responsiveness. Its goal is to provide you with simple educational materials that will help in your understanding of new or revised Medicare policies.

CMS Medicare Learning Network is certainly a one-stop shop for Medicare fee-for-service providers!

We provide you simple, instant connection to official code descriptors & guidelines and other tools for CPT coding, HCPCS lookupthat help coders and billers to excel in the work they do every day.

Exclusive Dental WordPress Themes

Medical themes are designed to symbolize on the internet all those individual or organizations that are specially concerned in medical issues, such as hospitals, health insurance companies, drugstores, medical centers, dentist”s offices, physician”s personal Web-pages, veterinary clinics, health blogs, etc. WordPress is the most commonly used open source blogging tool and CMS in the world. There are millions of themes, web-designers using them to make their blog or website more striking. There are many site provides these best Dental WordPress Theme exclusively for dental professional, they can use simple theme to create most effective website for viewers. WordPress has changed the face of the website and method of publishing content on the web as it provides the huge number of beautiful Free WordPress Themes to the bloggers to choose from and create a biased and beautiful websites. The quality is the main apprehension of these websites and they try to supply the best and the most graceful themes to select.

Like it or not, your website will be judged on how it looks. The best content in the world cannot make up for an unprofessional, jumbled, or tasteless site design. Choosing the perfect design which is also user-friendly is always recommended. The most concern thing for any individual is their health, health is very important and obscure issue, and medical themes have been created to convey an almost evident reaction of comfort, security, tranquility and seriousness. Passable layouts, sensible use of color formats and finely selected images make the medical themes suitable for elegant medical websites. They can be personalized to a certain extent in order to fit the client”s needs and design specification.

You should take in forethought the design of the site, its features and exploit its search engine optimization. All of these can be done in a go if you decide to get
Dental WordPress Themes. If you considering creating an informative dental related website then look for the best and most suitable Dental WordPress Themes, with the medical WordPress themes you do not have to think of a design for your website. The designs are plenty to choose for dental business website. Choosing the content oriented theme always helps to showcase their expertise and tools and technique they are using to treat their patients and also gives important information and dental care requirements. Everyone should take care of their dental problems immediately, all these relevant stuff, many of us may not be aware of, when we browse the net we can find the reliable information if the professional provide the exclusive information for viewers.

Electronic Health Records And Medicare

The move to get Medicare health records into the electronic health records arena started back in May of 2008. It happened when the Secretary of the Department of Health and Human Services gave a directive to the Centers for Medicare and Medicaid Services.

Basically, the Secretary told them to make a plan, which he called a demonstration imitative to make raise the quality of health care Medicare recipients received. There was a reward system involved in this demand for the organizations that the CMS would get involved in developing this system of health information technology for CMS in twelve states.

The Secretaries idea was that using electronic health records would vastly change the methods for practicing and delivering medicine. Along with improving the care that Medicare recipients receive it would net a big monetary savings for the government. The point of the plan was to encourage doctors to adopt electronic health records as their means of record keeping.

The directive said to get different local organizations picked as partners in the community to implement the demonstration. The organizations for each of the twelve states in the project had to already be working to make use of electronic health records the norm. These organizations needed to be involved in dealing with the medical people in a given area before becoming part of this project and in particular in relationship with primary care physicians. This could be an association with professional medical associations.

Examples of the types of organizations that would qualify to be part of this project to expand the use of electronic health records are Better Quality Information to Improve Care for Medicare Beneficiaries and Charted Value Exchange.

The job of these selected organizations was to organize a local area to get doctors cooperating in using electronic medical records. Around 2400 medical offices in the range of small to medium recruited into the project are the goal.

This is a test project to see how it would work and how-to proceed. A control group was assigned and the others were picked randomly. The places where the demonstration is conducted have two hundred medical offices participating. Four states were put in motion to begin with and in 2009 the other eight will be implemented.

It seems that if the demonstration project goes will in the eye of the powers that be then Medicare Services will be a large example of how using electronic health records improves a patient’s quality of health care and an example of the large savings to be had when that record keeping system is employed.

People that are concerned about the state of health care in the United States would like to hear more about how this demonstration is proceeding. It is important for Medicare beneficiaries, the taxpayer, and the medical community to know what actions will improve the overall health of the citizens of this country, including those on Medicare. Especially at time in our countries history where many people don’t have access to good healthcare and when the U.S. government has a huge deficit. The source of this information is the Centers for Medicare and Medicaid Services where more details can be obtained.