Three weeks ago, I wrote an article “One-on-One: Does It Only Apply to Medicare“. Of all the articles I have written and posted since Gawenda Seminars started in 2004, this one received the most blog posts, most email questions, and even in one case, a Gawenda Gold Member waking up at night in a full blown sweat wondering if they had done something wrong all these years. Why did they have a nightmare because of that article? It all had to do with the term “qualified healthcare professional” and using therapist as an example of a qualified healthcare therapist. That

Medicare Fee-For-Service (FFS) claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will continue to incur a 2 percent reduction in Medicare payment until further notice. Claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), including claims under the DMEPOS Competitive Bidding Program, will continue to be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment

On February 9, 2016, a federal appeals court reversed a lower court’s dismissal of a lawsuit brought by the AHA and several hospitals, which sought to compel the Department of Health and Human Services to meet its congressionally mandated deadlines for reviewing Medicare claims denials. Saying that the backlog of delays has gotten “worse, not better,” the appeals court sent the case back to the lower court, noting that, “in all likelihood,” the lower court should order the administration to comply with the appeals deadlines if HHS or Congress fails to make meaningful progress toward solving the problem within a

Two weeks ago, I wrote an article on “One-on-One: Does It Only Apply to Medicare“. The article definitely stirred up some conversation and hopefully cleared up several of the myths that exist concerning one-on-one and Medicare versus private insurance carriers. In this weeks article, I thought I would try and clear up another huge issue and that is what is the difference between individual therapy and group therapy and how do I know which one I am doing? I will also answer the question “When I am working one-on-one with Patient A and observing Patient B doing their exercises, is

The Centers for Medicare and Medicaid Services is proposing to implement a Medicare demonstration project, which they believe will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to Medicare beneficiaries. This demonstration would help assure that payments for home health services are appropriate before the claims are paid, thereby preventing fraud, waste, and abuse. As part of this demonstration, CMS proposes performing prior authorization before processing claims for home health services in: Florida, Texas, Illinois, Michigan, and Massachusetts. CMS would establish a prior authorization procedure

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews. CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will

I receive many questions at my in-person seminars and via email that begin something like “I know we can’t have 2 Medicare patient’s being treated at the same time, but how about 2 patient’s with private insurance”? Or, “I know I need to be one-on-one with Medicare patient’s, but that does not apply to patient’s with private insurance, right”? Lastly, “I know if I have 2 Medicare patient’s in my facility for one hour during the same time period, I have to split the time between them, but if the 2 patient’s had private insurance, I could bill each for

The Centers for Medicare and Medicaid Services has a booklet on Medicare Advance Beneficiary Notices. The booklet includes information on the following topics: Types of ABNs Prohibitions and Frequency Limits Completing the ABN Collecting Payment from the Beneficiary Financial Liability and the ABN Claim Reporting Modifiers Resources To access the complete booklet, click