May 3, 2023
Transitional care management (TCM) services are intended to help a patient transition, upon discharge, from an inpatient setting back to their home setting. Here are several areas you will want to look into for proper coding, documentation, and billing guideline use:
Who are the eligible providers that can perform TCM services?
Who can perform the non-face-to-face vs. face-to-face portion of the TCM service?
What types of locations are approved for post-discharge TCM services?
April 17, 2023
The Public Health Service Act, initiating the public health emergency (PHE), was declared on January 31, 2020. It has been renewed 13 times since then. The PHE was put into place in response to the COVID-19 pandemic. Several temporary waivers and flexibilities have been implemented by state and federal governments in response to the challenges faced throughout the nation. On January 30, 2023, President Joe Biden announced that the PHE will end on May 11, 2023. The end of the PHE signals the termination of the temporary waivers/flexibilities that were implemented throughout the pandemic (there are a few flexibilities that will extend past May 11, 2023). Healthcare organizations will need to re-examine their current policies, procedures, processes, workflows, etc. in preparation to transition back to “normal” operations.
April 11, 2023
On April 10, 2023, CMS released a proposed rule that will impact inpatient and long-term care hospitals (LTCH). The proposed rule recognizes homelessness as a Social Determinant of Health (SDOH), looks to increase equity & safety, and reduce preventable harm. For FY 2024, acute care hospitals who meet the requirements could see an increase in payments of 2.8% ($3.3B). LTCHs will also see an increase in the payment rate by 2.9%, however this will be an overall “decrease by 0.9% ($24M), primarily due to a projected decrease in high-cost outlier payments in FY 2024 compared to FY 2023.” (CMS Press release https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-improve-patient-safety-and-promote-health-equity?utm_source=newsletter&utm_medium=email&utm_campaign=name_ocr_cms_updates_auditing_for_compliance&utm_term=2023-04-11)
April 11, 2023
On April 4, 2023 CMS announced that the current Advanced Beneficiary Form (ABN) will expire on June 30, 2023. The updated ABN will go into effect on June 30, 2023 and expire on January 31, 2026.
The ABN is used by providers who know that a service is not covered or will be denied by the Medicare fee-for-service (FFS) program. Prior to providing the service, an ABN must be offered to the patient, so that they can decide whether or not to have the service and be financially responsible for the service. The ABN will list the service, the reason the service is not covered by Medicare, and an estimate of how much the patient can expect to pay. The patient will choose one of three options listed below and then sign and date the form:
March 24, 2023
CMS issued notice on March 24, 2023 to Medicare Advantage Organizations, Part D Plan Sponsors, and Medicare-Medicaid Plans that the temporary enforcement discretion policy would end when the PHE ends on May 11, 2023. This means the flexibilities these organizations implemented during the COVID-19 PHE will end and they will need to follow current statutory and regulatory requirements.
March 17, 2023
Former Naval officer, Jordan Thomas Broome, has been sentenced to 66 months in prison for submitting fraudulent Durable Medical Equipment (DME) claims of over $2.15M. Aided by other bad actors (providers who would “robo-sign” prescriptions for DME equipment for patients never seen), Broome illegally obtained over 2,000 Medicare beneficiaries’ personal information and mailed them DME equipment which they never asked for, nor needed. Read the full Press Release.
March 14, 2023
The Supreme Court of the United States (SCOTUS) denied Pfizer’s petition to review the Second Circuit’s Court of Appeals ruling that found Pfizer in violation of the anti-kickback statute. Two of Pfizer’s cardiac medications have a patient out-of-pocket cost of more than $1,000 per month.
March 02, 2023
As mentioned in a previous article, an individual or entity can be excluded from participating in Federal health care programs for a variety of reasons. The individual/entity will receive notification from the OIG indicating the period of time for which they are going to be excluded.
02/28/23
In January 2023, the Office of the Inspector General (OIG) collected over half-a-million dollars in Civil Monetary Penalties (CMP) from three health care organizations that employed individuals who were excluded from participating in any Federal health care program.
It is critical for providers to keep strict control of their prescription pads and access into e-prescribing.
An office manager in Chicago, IL has been sentenced to federal prison for writing over 3,000 fraudulent opioid prescriptions for individuals who were not patients of the provider. She and her co-conspirator used family and friends, who were not patients nor in need of opioid medications, to take the fraudulent prescriptions to the pharmacy to get filled and then return the drugs to them. Some of these drugs were later sold throughout Chicago, for profit.
