MRO Compliance

FEBRUARY 3, 2025

HEDIS audits are important for Medicare and Medicaid health plans because data is used to determine the efficacy of a payer to care for its members. For Medicare Advantage plans, the HEDIS review process contributes to the Star Rating system, which evaluates plan quality. Measures Collected Using Electronic Clinical Data Systems.

Patient Satisfaction 147

Patient Satisfaction Compliance Medicare Medicare 147

Medisys Compliance

FEBRUARY 19, 2025

Billing Update: Medicare Radiology Reimbursement Cuts 2025 Effective January 2025, radiology practices nationwide are facing reduced Medicare reimbursements due to finalized changes in the Physician Fee Schedule. Now, in February 2025, these proposed rules are our current reality. Here are key steps you can take: 1.

Medicare 59

Medicare Medicare Medical Billing Outsourcing Medical Billing 59

MRO Compliance

OCTOBER 31, 2024

During the performance year, there’s no way for providers or vendors to track or estimate cost data since CMS calculates it based on Medicare claims data after the performance period ends. If your final MIPS score is lower than expected, it’s natural to feel concerned, especially when Medicare payment adjustments are on the line.

Medicare 147

Medicare Medicare Payment Systems 147

Hall Render

JANUARY 29, 2025

The Centers for Medicare & Medicaid Services (CMS) is reinforcing its emphasis on hospice quality of care and identifying fraud. Hospice surveys are performed before their initial certification for Medicare participation. Identifying Fraud : Detecting practices that jeopardize patient safety or Medicare program integrity.

Fraud 80

Fraud Medicare Medicare Compliance 80

Healthcare IT News - Telehealth

NOVEMBER 10, 2020

Prepare Now for Anticipated Changes to Medicare and Private Payer Rules. The Centers for Medicare and Medicaid Services (CMS) is expected to issue new rules for telehealth in the release 2021 Physician Fee Schedule later this year. Today, Medicare reimburses for specific services when delivered via live video.

Public Health 161

Public Health Medicare Medicare COVID-19 161

Healthcare IT Today

FEBRUARY 22, 2023

There’s widespread consensus that payments to Medicare Advantage Organizations (MAOs) are a mess. These programs, which care for more than 30 million of the nearly 64 million Medicare enrollees , operate on the cutting edge of health care and suffer serious problems in data collection and billing.

Medicare 113

Medicare Medicare Overpayments Overpayment 113

Electronic Health Reporter

JUNE 16, 2021

The article Vyne Medical Launches Refyne, a SaaS Platform To Facilitate Electronic Submission of Medicare Audit Responses appeared first on electronichealthreporter.com. Purpose built for healthcare, Refyne is designed with the look and feel of a modern consumer-facing app and features to help optimize administrative workflows […].

Medicare 172

Medicare Medicare 172

Healthcare It News

FEBRUARY 2, 2023

This system allows the creation of Medicare-compliant GP management plans and team care arrangements, which can be automatically shared with the care team. Moreover, INCA enables third-party services to participate in team care arrangements without installing the system; they can gain access to shared documents by receiving an encrypted link.

Licensing 284

Licensing Medicare Medicare 284

Healthcare It News

SEPTEMBER 16, 2024

By making use of technologies such as artificial intelligence, providers can empower senior patients with the extra guidance and support that informs them and gets them to the point of care, according to Karl Ulfers, cofounder and CEO at DUOS, a senior-focused digital care navigation platform designed for Medicare beneficiaries.

Medicare 311

Medicare Medicare Public Health Health Analytics 311

Healthcare It News

SEPTEMBER 9, 2022

The Centers for Medicare and Medicaid Services is inviting patients and their families, providers, clinicians, consumer advocates, healthcare professional associations, individuals serving underserved communities and all CMS stakeholders serving populations facing disparities in health and healthcare to submit public comments by November 4.

COVID-19 298

COVID-19 Medicaid Medicaid Public Health 298

Medisys Compliance

MARCH 21, 2025

But behind every effective treatment plan is the challenge of accurate documentation and billing. Whether you’re working with Medicare or private insurance, understanding how billing units work can significantly impact your reimbursement rates, reduce claim denials, and ensure compliance with payer guidelines.

Medical Billing Outsourcing 59

Medical Billing Outsourcing Compliance Medicare Medicare 59

Medisys Compliance

JANUARY 16, 2025

The Centers for Medicare & Medicaid Services (CMS) provides comprehensive behavioral health billing guidelines, which can be overwhelming due to their technical nature and breadth. Providers must ensure that these services meet Medicares criteria for medical necessity.

Medicare 59

Medicare Medicare Medical Billing Outsourcing Fraud 59

AIHC

APRIL 18, 2022

Written by: Thomas "Trent" Jackson, BS, CCRS Medicare bad debts present Medicare Part A providers an opportunity to recover reimbursement dollars they otherwise would have missed. Provided that a proper log is kept, total uncollected Medicare co-insurance and/or deductibles can be claimed on the cost report for 65% reimbursement.

Medicare 98

Medicare Medicare Medicaid Medicaid 98

Medisys Compliance

MARCH 19, 2025

Medicare Coding Overview For practices billing Medicare, it’s crucial to stay updated with the National Correct Coding Initiative (NCCI) edits, which aim to prevent improper payments. Private insurers might have proprietary coding rules or require pre-authorization for a broader range of procedures compared to Medicare.

Medicare 59

Medicare Medicare Medical Billing Outsourcing Medical Billing 59

HIT Consultant

DECEMBER 3, 2024

Many care settings are required to perform elaborate intake and documentation before even beginning treatment for a patient. The Centers for Medicare & Medicaid Services (CMS) added codes for Digital Mental Health Treatment in its 2025 Medicare Physician Fee Schedules. Automating intake and paperwork.

FDA 111

FDA Medicare Medicare Medicaid 111

Medisys Compliance

JUNE 27, 2022

The Centers for Medicare and Medicaid Services (CMS) has announced a shift in its eligibility criteria for coverage of lung cancer screening using low-dose CT (LDCT), with implementation date of October 3 rd , 2022. CMS Announcement for Revised Coverage. Reduced the eligibility criteria for the reading radiologist.

Medicare 97

Medicare Medicare Medical Billing Medical Billing Outsourcing 97

Medisys Compliance

DECEMBER 24, 2024

However, billing for teletherapy services can be complex, requiring a deep understanding of coding, documentation, and payer-specific policies. Some of the documentation tips for CPT codes include: Include the start and end time of the session. Document that the service was provided via telehealth, including the platform used (e.g.,

Medical Billing Outsourcing 59

Medical Billing Outsourcing Medicaid Medicaid Medical Billing 59

Healthcare It News

OCTOBER 31, 2022

Through the secure collection, documentation, reporting, access and use of data across provider types, ONC aims to address health inequities that have their root causes in poverty and racism. They're not limited to using the SDOH standards in ONC's guide in their work, according to the post. THE LARGER TREND.

Licensing 342

Licensing Medicaid Medicaid Health Outcomes 342

Healthcare Law Blog

FEBRUARY 1, 2023

On January 30, 2023 , the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). One thing that is certain, CMS can expect further challenges to its RADV audit methodology. 3d 1, 18 n.19

Medicare 105

Medicare Medicare Overpayments Overpayment 105

Medisys Compliance

DECEMBER 30, 2024

Obsessive-compulsive disorder Ensure documentation matches the diagnosis and treatment provided. These may include pre-authorization, session limits, or specific documentation standards. Medicare: Pays based on the Medicare Physician Fee Schedule (e.g., $85$130 Common ICD-10 codes include: F33.1: ICD-10 Code F51.01

Medical Billing Outsourcing 59

Medical Billing Outsourcing Medical Billing Medicare Medicare 59

Healthcare IT News - Telehealth

FEBRUARY 22, 2021

Among the allegations are that Wolfe and her conspirators submitted well over $400 million in illegal durable medical equipment claims to Medicare and the Civilian Health and Medical Program of the Department of Veterans, relying on the guise of "telemedicine" to explain the unusually high volume of claims. THE LARGER TREND.

Fraud 199

Fraud Telemedicine US Department of Health and Human Services COVID-19 199

Healthcare IT News - Telehealth

MAY 13, 2022

As outlined in court documents , marketers identified Medicare and TRICARE beneficiaries to target for expensive medications – such as pain creams, scar creams, eczema creams and migraine medication – and durable medical equipment, including wrist, shoulder, knee and ankle braces. " WHY IT MATTERS. ON THE RECORD.

Fraud 172

Fraud Doctors COVID-19 Medicare 172

Healthcare IT News - Telehealth

JULY 9, 2020

The Centers for Medicare and Medicaid Services has put together further detailed guidance for how healthcare providers should be documenting and reporting electronic clinical quality measures for telehealth encounters.

Payment Systems 216

Payment Systems Medicaid Medicaid Medicare 216

AIHC

MARCH 31, 2025

The "Sunshine Act," officially known as the Physician Payments Sunshine Act, mandates those manufacturers of drugs, medical devices, and biologics report payments and transfers of value to physicians and teaching hospitals to the Centers for Medicare & Medicaid Services (CMS).

Compliance 64

Compliance COVID-19 Compliance Officers Medicaid 64

Medisys Compliance

JANUARY 23, 2025

Will Medicare Stop Paying for Telehealth in 2025? One of the pressing questions for healthcare providers is whether Medicare will continue reimbursing telehealth services in 2025. The good news is that Medicare has extended many telehealth flexibilities initiated during the COVID-19 Public Health Emergency (PHE) through March 2025.

Medical Billing Outsourcing 59

Medical Billing Outsourcing Medicare Medicare Medical Billing 59

Healthcare IT Today

OCTOBER 23, 2024

The following is a guest article by David Lareau, CEO at Medicomp Systems A couple of years ago, we predicted an impending “explosion” of Medicare Advantage (MA) fraud and penalties. For instance, an LLM might create documentation stating a patient has diabetic cataracts when they actually have age-related (senile) cataracts.

Medicare 75

Medicare Medicare Fraud Doctors 75

Health Law Advisor

FEBRUARY 2, 2023

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. The final rule codifies long-awaited regulations first proposed by CMS in 2018.

Medicare 98

Medicare Medicare Overpayments Overpayment 98

MRO Compliance

JANUARY 16, 2025

To address these gaps, the Centers for Medicare & Medicaid Services (CMS) now mandates the use of FHIR-based APIs for data sharing. For payers, staying ahead of these changes means investing in systems that track documentation and manage disputes efficiently.

Overpayments 130

Overpayments Overpayment Regulatory Compliance Patient Satisfaction 130

Healthcare IT News - Telehealth

SEPTEMBER 20, 2021

"We have seen all too often criminals who engage in health care fraud – stealing from taxpayers while jeopardizing the health of Medicare and Medicaid beneficiaries," said Deputy Inspector General for Investigations Gary L. More than $1.1 billion of that loss involved allegedly fraudulent claims related to telemedicine.

Fraud 206

Fraud Telemedicine Medicare Medicare 206

Healthcare IT News - Telehealth

JANUARY 30, 2023

While it made "significant" changes to the Medicare Benefits Schedule (MBS), the expanded telehealth services were "only partly supported by sound implementation arrangements." " The audit found that it did not require key implementation decisions and plans to be documented.

COVID-19 188

COVID-19 Governance Medicare Medicare 188

Verisys

FEBRUARY 3, 2025

A well-organized checklist can simplify this process and help avoid delays caused by missing or incomplete required documents. Understanding Medical Credentialing Healthcare credentialing ensures that both the professional credentials and the necessary documentation are verified.

Malpractice 52

Malpractice Regulatory Compliance Licensing Compliance 52

Healthcare IT News - Telehealth

JUNE 16, 2020

“We also needed to be able to conduct patient visits while simultaneously documenting the encounter, without disruption to our workflow,” he explained. Additionally, the technology enables him to document while he is doing a patient visit without losing eye contact.

COVID-19 211

COVID-19 Telemedicine HIPAA Nurses 211

Healthcare IT News - Telehealth

APRIL 10, 2019

The illegal kickback scheme allegedly involved companies that received money in exchange for referral of Medicare beneficiaries by medical professionals for back, shoulder, wrist and knee braces that are medically unnecessary. WHY IT MATTERS. billion in losses. ON THE RECORD. WHAT ELSE TO KNOW.

Fraud 167

Fraud Telemedicine Medicare Medicare 167

Healthcare IT Today

OCTOBER 19, 2024

John summarized a study in the American Journal of Managed Care highlighting how real-time interventional analytics reduced 30-day readmissions and Medicare spending per beneficiary for Penn Medicine affiliates. Read more… Supporting the Complete Path of Incoming Healthcare Documents.

Health Insurance 90

Health Insurance Medicare Medicare Hospitals 90

Verisys

DECEMBER 29, 2024

Without proper credentialing, physicians cannot apply for privileges, bill for services, or receive reimbursement from Medicare and other payers. Primary Source Verification Healthcare organizations contact educational institutions, licensing boards, and past employers to verify the accuracy of submitted documents.

Malpractice 52

Malpractice Licensing Regulatory Compliance Hospitals 52

Healthcare IT News - Telehealth

OCTOBER 27, 2020

The Centers for Medicare and Medicaid Services announced earlier this month , for example, that it would add 11 virtual services to its reimbursement list during the COVID-19 public health emergency – following in the footsteps of its earlier flexibilities for virtual care.

COVID-19 202

COVID-19 Governance Medicare Medicare 202

Healthcare It News

DECEMBER 6, 2023

As an FQHC, Evara did not qualify for reimbursement from Medicare. "The second item is to have a well thought out and documented rollout plan, with a detailed marketing plan," he continued. Evara also needed a way to better monitor patients being discharged from the ER to reduce the likelihood they would need to come back.

Nurses 321

Nurses Medicaid Medicaid Hospitals 321