The Centers for Medicare and Medicaid Services (CMS) recently announced that they would be slightly revising its, ‘Two-Midnight Rule’, a policy well-known by healthcare providers due to its strict guidelines.

The OIG states “We will examine Medicare payments to physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures to assess the appropriateness of Medicare payments for high-use sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 Medicare payments for Current Procedural Terminology codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedures. Medicare will not pay for items or services that are not “reasonable and necessary.” To the extent that repeated diagnostic testing is performed on the same beneficiary and the prior test results are still pertinent, repeated tests may not be reasonable and necessary.”[1]

The Centers for Medicare & Medicaid Services (CMS) announced mid-February its final rule that will necessitate Medicare Parts A and B health care providers and suppliers alike to report and return self identified overpayments. This Final Rule will be implemented under sections of the Affordable Care Act (ACA). Below lists a synopsis of the major provisions that are set to become effective March, 2016.

In early October of 2015, The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) has released its final rule for both the Meaningful Use and Electronic Healthcare Record (EHR) Incentive program.

CPT (Current Procedural Terminology) defines a modifier as, “a combination of two characters letters or alphanumeric codes that are meant to convey additional information regarding the procedure or services offered by the physician or hospital.”

CPT code 99211 is defined as an office or other outpatient visit for the evaluation and management (E/M) of an established patient that may not require the presence of a physician. Usually the presenting problem is minimal and five minutes are typically spent with the patient performing or supervising these services.

The United States government has been committed to curtailing fraud, waste, and abuse across the realm of federal healthcare, since the Health Care Fraud and Abuse Control (HCFAC) Program was implemented in 1997. Since the creation of the HCFAC, more than $27.8 billion dollars has been returned to the Medicare Trust Fund due to the efforts of fraud, waste, and abuse programs.

By now, most of the medical industry has made the transition to electronic health records (EHR) to store patient health information.  Most platforms have a multitude of options to contain information through tabs, templates, and working documents. Although this may create a better means of sharing and cataloging data, it also enables new functionality that that changes the role of traditional auditing.  Back in January 2014, Inspector General Daniel Levinson conducted a study to understand contractor audit practices relating to identification of improper billing practices and billing fraud (see EXECUTIVE SUMMARY: CMS AND ITS CONTRACTORS HAVE ADOPTED FEW PROGRAM INTEGRITY PRACTICES TO ADDRESS VULNERABILITIES IN EHRSOEI-01-11-00571).  The results were somewhat surprising given the technologic capabilities of the government and the push for meaningful use compliance across the US.  Bottom line, the OIG concluded that CMS contractors have adopted few practices to address EHR vulnerabilities.

On Tuesday, April 14th, the Senate overwhelmingly passed the long-awaited Medicare Access and CHIP Reauthorization Act of 2015 with a 92 to 8 vote. This vote will repeal the flawed Sustainable Growth Rate (SGR) and dispose of a 21% Medicare payment cut that was originally to take effect earlier in April. This bill was then signed into law by President Obama on Thursday, April 16th.

The 2014 Medicare Physician Fee Schedule expired on March 31st, 2015. The new Medicare rates are scheduled for implementation on Wednesday, April 1st, 2015 and propose a 21% cut in reimbursement to physicians.