On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) released the final rule for services reimbursed under the Medicare Physician Fee Schedule (MPFS). The final rule contains information on the 2014 conversion factor used to determine payment, 2014 therapy cap, therapy cap exception process, manual medical review process, application of the therapy cap to critical access hospitals, application of the therapy cap to hospital outpatient departments, significant changes to the PQRS program for private practices, and incident-to-physician services, just to name a few. Therapy Cap, Exception Process & Review for Claims Exceeding $3700 The therapy cap dollar

There are two levels in the Medicare Appeals process (Level III and Level V) that requires an amount in controversy (AIC) in order for the request to be considered. Following the Qualified Independent Contractor’s (QIC’s) decision, a party to the reconsideration may request an Administrative Law Judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. In order to request a hearing by an ALJ, the amount remaining in controversy must meet the threshold requirement. For calendar year 2014, the amount

The Centers for Medicare and Medicaid Services (CMS) has released the 2014 deductible, coinsurance and premium rates. CMS announced that premiums for Medicare Part B will remain flat in 2014 and the Medicare Part B deductible will remain $147.00 as it was in 2013. Premiums for Medicare Part B will remain at $104.90, the same as it was in 2013. The Medicare Part A premium will decrease $15.00 in 2014 to $426.00. Part A pays for inpatient hospital care, skilled nursing facilities and some home care services; however, 99% of Medicare users do not pay premiums for Part A. The

On November 1, 2013, the Centers for Medicare and Medicaid Services (CMS) issued additional guidance regarding the two-midnight inpatient hospital medical review and admission criteria. In addition, CMS issued 2 documents setting forth more details on the “probe and educate” audits that will be conducted by Medicare Administrative Contractors. To read the additional guidance and access the 2 documents, click HERE and to access CMS FAQs on the 2-midnight policy, click HERE.

UnitedHealthcare (UHC) has updated their speech generating policy due to Section 6407 of the Affordable Care Act (ACA) that established a face-to-face encounter requirement for certain items of durable medical equipment (DME) (including speech generating devices). The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME. Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-to-face

National Government Services (NGS) has updated their outpatient PT and OT local coverage determination for private practices and non-private practices. The changes concern how often a Progress Report is due when the patient exceeds the therapy cap and required specific documentation of referring physician re-examination and re-evaluation which demonstrates the need for physical therapy services, in cases where services exceed the 90-day certification period, or where services have exceeded the therapy cap. This positive change impacts providers in the states of CT, IL, ME, MA, MN, NH, NY, RI, VT, and WI. To read the changes, click

On October 28, 2013, the Centers for Medicare and Medicaid Services (CMS) announced that premiums for Medicare Part B will remain flat in 2014 and the Medicare Part B deductible will remain $147.00 as it was in 2013. Premiums for Medicare Part B will remain at $104.90, the same as it was in 2013. The Medicare Part A premium will decrease $15.00 in 2014 to $426.00. Part A pays for inpatient hospital care, skilled nursing facilities and some home care services; however, 99% of Medicare users do not pay premiums for Part A. The Medicare Part A deductible that beneficiaries

The Office of the Inspector General (OIG) has released a report regarding the billing of and reimbursement for outpatient therapy services by Spectrum Rehabilitation, LLC (Spectrum). The OIG estimates that Spectrum, operating in New Jersey, improperly received at least $3.1 million in Medicare reimbursement for outpatient occupational and physical therapy services that did not comply with certain Medicare requirements. Of the 100 claims in our random sample, Spectrum properly claimed Medicare reimbursement for 17 claims. However, Spectrum improperly claimed Medicare reimbursement for the remaining 83 claims. Of these 83 claims, 44 contained more than 1 deficiency. Deficiencies included Medicare physician