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

National Government Services (NGS) has completed the transition and is now the primary Medicare Administrative Contractor (MAC) in the states of Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont. To access the NGS local coverage determinations, appeals process, medical review, NGS monthly newsletter, and other transition information, click

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

The Centers for Medicare and Medicaid Services (CMS) has released instructions to the MACs on 100% Prepayment Review and Random Review. Random review is defined as review conducted without a specific reason or logic to substantiate the cause for review. MACs have the discretion to conduct random reviews of services; however, CMS does not recommend random reviews. 100% prepayment review is defined as review of every claim submitted by a targeted provider for a specific code (i.e. DRG, CPT, HCPCs). 100% prepayment review also includes review of every claim submitted by the targeted provider. MACs have the discretion to conduct

The Office of the Inspector General has released a report on the first level of the appeals process for Medicare Parts A and B from 2008-2012. Medicare refers to the process for the first level of appeals as redetermination. In 2012, contractors processed 2.9 million redeterminations, which involved 3.7 million claims, an increase of 33 percent since 2008. Although 80 percent of all redeterminations in 2012 involved Part B services, redeterminations involving Part A services have risen more rapidly. In 2012, the Medicare program denied 139,275486 million claims, but providers only appealed 3,664,599 million claims which amounts only to 2.6%