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  • Medicare Managed Care Appeals & Grievances

    Medicare health plans, which include Medicare Advantage (MA) plans – such as Health Maintenance Organizations, Preferred Provider Organizations, Medical Savings Account plans and Private Fee-For-Service plans – Cost Plans and Health Care Prepayment Plans, must meet the requirements for grievance and appeals processing under Subpart M of the Medicare Advantage regulations.  For a detailed discussion of the Medicare managed care grievance and appeals processes, click here.


    Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights. If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination.  Additionally, Medicare health plan enrollees receiving covered services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast, or expedited, review if they think their Medicare-covered services are ending too soon.



     

  • New Medicare cards offer greater protection to more than 57 million Americans


    New cards will no longer contain Social Security numbers
    , to combat fraud and illegal use

    The Centers for Medicare & Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. The new cards will use a unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI), to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card. CMS will begin mailing new cards in April 2018 and will meet the congressional deadline for replacing all Medicare cards by April 2019. Today, CMS kicks-off a multi-faceted outreach campaign to help providers get ready for the new MBI.

  • Two-Midnight Rule: Initial Reviews to Resume

    Having taken time out for retraining and internal audits, contractors may resume initial-phase reviews of Medicare reimbursement claims for short-stay inpatient hospital care, CMS says.

  • 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.

  • Don't underestimate the importance of good documentation

    It’s an unfortunate part of healthcare today—the lawsuit. Are you ready if one is filed against your organization?

  • Q&A: Should we hardcode modifier -CT?

    Q: Our radiology department is requesting that we add a new modifier to their charge description master (CDM), modifier –CT (computed tomography [CT] services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard). They want this added to the CT scan line items, but they are not sure if it is for all of the items or only certain ones. Can you provide more information that might help us know how to proceed?

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WHAT'S THIS?
 

Medicare Compliance Essentials Training Compendium

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    Ensure compliance across your organization at an affordable price.

    HCPro has brought together seven of its most popular Medicare compliance training handbooks into a single collection, offering Medicare professionals a one-stop resource for regulatory and practical guidance. The Medicare Compliance Essentials Training Compendium is a full-size book featuring a brand-new introduction with guidelines on using the content and tools in each handbook for training purposes. The individual handbooks can also be downloaded and printed for training unlimited numbers of staff.

    Developed by industry-leading experts, this compendium simplifies Medicare compliance by providing a go-to source for training on critical billing and reimbursement issues, helping to ensure the delivery of a unified message throughout the organization. The book and downloadable handbooks cover topics such as:

    • Billing for ancillary bedside procedures
    • Patient status training for utilization review
    • Observation services
    • Condition codes 44 and W2
    • Inpatient-only procedures
    • Denials management
    • Revenue integrity

    Learn more