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Tag Archives: Claims

Q&A: Submitting claims for observation services

Q: Did something change with the observation services Composite APC in 2016? The director of patient financial services says we no longer receive payment for it.

A: The observation services Composite APC (APC 8009) was replaced with a single comprehensive APC (C-APC 8011) for CY 2016. Along with the new C-APC comes new status indicator J2. Services assigned to J2 are considered to be adjunctive services and components of C-APC 8011, and this will result in a single payment for these services reported as part of the comprehensive observation services APC. The J2 designation and the payment are based at the claims level and not per date of service.
 
The good news is that the requirements to meet the observation services C-APC are the same as for the Composite APC (e.g., clinic/ED visit, 8 or more units of G0378, etc.). Even more good news is that the ED visit level requirement now includes all Type A and Type B ED levels and critical care; the level is no longer limited to the higher ED visit levels.
 
Be sure that all services provided continue to be reported to insure that all costs pertaining to the individual patient’s scenario are included in your claims data. CMS will continue to expect and rely on the claims data for rate setting under the OPPS.
 
For more information, see the Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.3, 10.4, 290.5.1. 290.5.2 and new section 290.5.3.
 
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Revant Solutions,in Fort Lauderdale, Florida, answered this question.

HCPro.com – APCs Insider

Medicare Advantage Organization and Former COO to Pay $32.5 Million to Settle False Claims Act Allegations

Freedom Health Inc., a Tampa, Florida-based provider of managed care services, and its related corporate entities (collectively “Freedom Health”), agreed to pay $ 31,695,593 to resolve allegations that they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans, the Justice Department announced today. In addition, the former Chief Operating Officer (COO) of Freedom Health Siddhartha Pagidipati, has agreed to pay $ 750,000 to resolve his alleged role in one of these schemes. You can read the full update on the justice.gov website – here.

The post Medicare Advantage Organization and Former COO to Pay $ 32.5 Million to Settle False Claims Act Allegations appeared first on The Coding Network.

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FTC fines software vendor over false encryption claims

Henry Schein Practice Solutions, Inc., a provider of office management software for dental practices, agreed to pay $ 250,000 to the Federal Trade Commission (FTC) to settle charges that Schein lied to consumers about the level of encryption its product provides. The charges specifically address the level of security offered by Schein’s Dentrix G5 software, an office and data management tool that was marketed to address the day-to-day operations of a dental office including database storage of patient records. The software, originally launched in 2012, was marketed as offering encryption capabilities that would help a practice meet HIPAA security requirements.

In contradiction to Schein’s statements to consumers, Dentrix G5 did not use the National Institute of Standards and Technology (NIST) industry standard Advanced Encryption Standard (AES) security. Schein was aware that its product used a less complicated data encryption method and continued to explicitly promote the software’s data encryption capabilities and claimed that the software met “data protection regulations” in marketing material, the FTC alleged in its complaint.

The U.S. Computer Emergency Readiness Team (US-CERT) issued a warning in 2013 about the data encryption method Schein used in its software. Dentrix G5 used Faircom c-tree-ACE which offers a weak level of obfuscation. The algorithm used in this method was called Faircom Standard Encryption, but the name was changed to Data Camouflage to distinguish it from standard encryption algorithms. Faircom describes their Data Camouflage as a supplement to existing security and not a replacement for other security systems. US-CERT notified Schein of this vulnerability on June 10, 2013.

Schein is required by the consent agreement to notify all customers who purchased Dentrix G5 that the software does not offer industry-standard encryption. Schein agreed to provide the FTC with ongoing progress reports on its notification program, and is prohibited from using false advertising to mislead consumers about its products’ data encryption and security capabilities.

The FTC published a description of the consent agreement in the Federal Register. The consent agreement is open for public comment for 30 days. The FTC will then decide whether to make the consent agreement final. The deadline for public comments is February 4.

HCPro.com – HIM-HIPAA Insider

The Top 3 Reasons for Radiology Claims Denials and How to Avoid Them

The goal of a well-managed radiology billing operation is to submit claims for services promptly and receive reimbursement as quickly as possible. Timely submission and prompt payment enhance the practice’s cash flow and keep the overall cost of billing at a minimum.  All too often, however, payment is delayed because the payer denies the claim for some reason. 


Medical Billing and Coding Blog

How to Avoid Radiology Claims Denials – Eligibility Problems

Claims for reimbursement of radiology services are most often denied by the payer, whether it is Medicare or a commercial insurance company, because they contain inaccurate information about the patient’s eligibility for coverage. This can occur for many reasons, some of which may not be within the control of the radiology practice, but it usually can be corrected by improving the process of recording data at the time of patient registration. In this new healthcare economy where radiology practices are under pressure to add value to the patient care delivery system, effective management of claims denials can strengthen the relationship between the practice or imaging center and the hospitals they serve.


Medical Billing and Coding Blog

How to Avoid Radiology Claims Denials – Authorization

This article continues our series focusing on how to avoid radiology claims denials. In our first article, we covered Patient Eligibility Problems.  Now let’s look at the topic of procedure authorization, specifically the failure to obtain proper authorization before the service is performed.


Medical Billing and Coding Blog

Paradigm Spine Agrees to Resolve False Claims Act Allegations

Recently, the US Department of Justice made an announcement that Paradigm Spine has agreed to resolve false claim accusations levied against it concerning the coflex-F® device. The department has stated that Paradigm Spine has allegedly provided its health care providers with incorrect information on claiming reimbursement for the coflex device.

Read the full article here: https://www.justice.gov/usao-md/pr/paradigm-spine-agrees-resolve-false-claims-act-allegations

The post Paradigm Spine Agrees to Resolve False Claims Act Allegations appeared first on The Coding Network.

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Holding of 2016 date-of-service claims for services paid under the 2016 Medicare physician fee schedule


On October 30, 2015, the calendar year (CY) 2016 Medicare physician fee schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare administrative contractors will hold claims containing 2016 services paid under the MPFS for up to 14 calendar days (i.e., Friday January 1, 2016, through Thursday January 14, 2016). The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MPFS claims for services rendered on or before Thursday December 31, 2015, are unaffected by the 2016 claims hold and will be processed and paid under normal procedures and time frames.

Reference: https://medicare.fcso.com/Fee_news/0307451.asp


Coding Ahead

Louisville Based MD2U and Its Principal Owners Admit To Violating The Federal False Claims Act And Being Liable For Millions

LOUISVILLE, KY – MD2U Holding Company, including its related companies and individually named owners (“Defendants”), have agreed to pay millions to resolve a government lawsuit alleging that they violated the federal False Claims Act by knowingly submitting false medical claims to Medicare and other government health care programs, altering records to support false claims, and providing services that were medically unnecessary U.S. Attorney John E. Kuhn, Jr. today announced….

MD2U also utilized an electronic medical records (EMR) system that permitted the NPPs to easily electronically cut, copy and paste medical notes from prior visits. The ability to migrate notes from visits that occurred weeks, months, or even years prior to the current patient encounter created the illusion that MD2U’s NPPs were performing a significant amount of work during their patient encounters when, in fact, they were not. If the documentation was deficient to bill the highest level code, MD2U would direct NPPs to go back and change the medical record – after the encounter had occurred – to falsely show that more work was performed during the visit in order to support the highest level billing.

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