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Do We Need an Order for Therapy to See Medicare Patients

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

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2016 Therapy Updates

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:

CMS to Expand RACs to Medicare Advantage

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 C RAC to increase the number of Medicare Advantage Organization contracts that are subject to some type of Risk Adjustment Data Validation (RADV) audit for each payment year. Our ultimate goal is to have all MA contracts subject to either a Comprehensive or Condition‐Specific RADV audit for each payment year.

This draft SOW describes the Part C RAC’s role in the existing RADV audit process, referred to herein as the Comprehensive RADV audits, and their role in additional audits of diagnosis data submitted to CMS by Medicare Advantage (MA) Organizations, referred to herein as Condition‐Specific RADV Audits. To read the draft SOW, click

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CMS Finalizes Prior Authorization Rule for DME

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 final rule online or in a pdf format, click

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