Occasionally, providers of therapy services may receive an overpayment from the Medicare program for which they are not entitled to keep. Providers may not know of this overpayment until they receive notice from their Medicare Administrative Contractor. There are also times when the provider of therapy services may be the one who notices the overpayment. In either instance, what must the provider do? In this article, I will answer the following questions: Why do overpayments occur? What is an overpayment? What is my responsibility if I realize I have received an overpayment? What is the collection process for my Medicare

A question I am often asked is does the Medicare program require we have an order to begin therapy in addition to the physician signing and dating our plan of care? There are actually 2 answers to this question and the answer also depends on your practice setting (i.e. private practice versus non-private practice settings). Under Medicare Part B therapy rules and regulations, the Medicare program does

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

On October 30, 2015, the 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

The Centers for Medicare and Medicaid Services (CMS ) has announced the dollar amount in controversy required for an Administrative Law Judge (ALJ) hearing or Federal District Court review for calendar year 2016. The amount that must remain in controversy for ALJ hearing requests filed on or before

The Centers for Medicare and Medicaid Services (CMS) has announced the 2016 Medicare premiums and deductibles. As the Social Security Administration previously announced, there will no Social Security cost of living increase for 2016. As a result, by law, most people with Medicare Part B will be “held harmless” from any increase in premiums in 2016 and will pay the same monthly premium as last year, which is $104.90. Beneficiaries not subject to the “hold harmless” provision will pay $121.80, as calculated reflecting the provisions of the Bipartisan Budget Act signed into law by President Obama. Medicare Part B beneficiaries