With a new year beginning in a few days, there is a new therapy cap dollar amount and new deductible for calendar year 2016 for Medicare beneficiaries. In addition, updates to the manual medical review process for claims exceeding $3700 have been implemented by the Medicare program. In this article, I will answer the following questions: What is the 2016 therapy cap dollar amount? What is the status of the therapy cap exception process in 2016? What is the 2016 Medicare Part B deductible? How does the 2016 Medicare Part B deductible impact the therapy cap? What is the manual

The Centers for Medicare and Medicaid Services (CMS) has issued a draft Statement of Work (SOW) to solicit comment on, and interest in, CMS entering into a contract with a Recovery Audit Contractor (RAC) to identify underpayments and overpayments and recouping overpayments associated with diagnosis data submitted to CMS by Medicare Advantage Organizations. Errors and omissions in the diagnosis data submitted to CMS by Medicare Advantage Organizations are the drivers of the 9.5% improper payment rate in Medicare Part C. Currently, CMS audits 30 Medicare Advantage Organization contracts (approximately 5%) per payment year. CMS is considering contracting with a Part

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor’s decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable. To read the