Claims Procedure for Plans Providing Disability Benefits. Final rule.

This document contains a final regulation revising the claims procedure regulations under the Employee Retirement Income Security Act of 1974 (ERISA) for employee benefit plans providing disability benefits. The final rule revises and strengthens the current rules primarily by adopting certain procedural protections and safeguards for disability benefit claims that are currently applicable to claims for group health benefits pursuant to the Affordable Care Act. This rule affects plan administrators and participants and beneficiaries of plans providing disability benefits, and others who assist in the provision of these benefits, such as third-party benefits administrators and other service providers.

2012 financial outlook: physicians and podiatrists.

Although the nationally unadjusted average Medicare allowable rates have not increased or decreased significantly, the new codes, the new coding regulations, the NCCI edits, and the Medicare contractors' local coverage determinations (LCDs) will greatly impact physicians' and podiatrists' revenue in 2012. Therefore, every wound care physician and podiatrist should take the time to update their charge sheets and their data entry systems with correct codes, units, and appropriate charges (that account for all the resources needed to perform each service or procedure). They should carefully read the LCDs that are pertinent to the work they perform. If the LCDs contain language that is unclear or incorrect, physicians and podiatrists should contact the Medicare contractor medical director and request a revision through the LCD Reconsideration Process. Medicare has stabilized the MPFS allowable rates for 2012-now physicians and podiatrists must do their part to implement the new coding, payment, and coverage regulations. To be sure that the entire revenue process is working properly, physicians and podiatrists should conduct quarterly, if not monthly, audits of their revenue cycle. Healthcare providers will maintain a healthy revenue cycle by conducting internal audits before outside auditors conduct audits that result in repayments that could have been prevented.

Fraud and abuse enforcement trends. What's hot for physicians and physician practices.

The Department of Health and Human Services Office of Inspector General (OIG) has dramatically expanded the scope and frequency of physician fraud and abuse investigations. Further, OIG has increasingly extracted financial settlements and obtained sanctions against physicians. This article identifies seven areas of investigation that will be given highest priority.

Medicare program; physician liability on non-assigned claims--HCFA. Final rule.

This rule establishes in regulations the circumstances in which a nonparticipating physician who does not accept Medicare assignment of a claim is required to refund to the beneficiary any amounts collected for physician services determined to be not reasonable and necessary. Its purpose is to extend limitation of liability protection to beneficiaries with non-assigned claims when the physician knew or could reasonably have been expected to know that Medicare would deny payment for the services. Physician appeal rights are also specified. This rule conforms our regulations to section 9332(c) of the Omnibus Budget Reconciliation Act of 1986.

Medicare program; standard claim forms for Part B claims completed and submitted by physicians, suppliers and other persons--HCFA. General notice with comment period.

This notice announces that effective April 1, 1992, Medicare carriers will no longer accept nonstandard claims. These are claims accompanied by attachments, in lieu of the biller entering required information in designated blocks of prescribed claims forms. This change is intended to eliminate costly and inefficient claims processing practices for Medicare carriers.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); reimbursement of providers, claims filing, and participating provider program--Office of the Secretary, DoD. Final rule.

This final rule implements provisions of the Department of Defense Appropriations Act, 1993, section 9011, which limits increases in maximum allowable payments to physicians and other individual professional providers (including clinical laboratories), authorizes reductions in such amounts for overpriced procedures, provides special procedures to assure beneficiary access to care, and establishes limits on balance billing by providers. Also, the final rule implements a provision of the National Defense Authorization Act for Fiscal Year 1992 that requires providers to file claims on behalf of CHAMPUS beneficiaries, builds into the CHAMPUS Regulation provisions that have been in effect for several years regarding the Participating Provider Program, and implements a new approach for CHAMPUS reimbursement for ambulatory surgery.

Health care programs: fraud and abuse; revised OIG exclusion authorities resulting from Public Law 104-191; correction--Office of Inspector General (OIG). HHS. Final rule; correcting amendment.

This document contains corrections to the final regulations which were published in the Federal Register of Wednesday, September 2, 1998 (63 FR 46676). The regulations addressed revisions to the OIG's administrative sanction authorities resulting from the Health Insurance Portability and Accountability Act of 1996, along with technical and conforming changes to the OIG exclusion authorities. A number of inadvertent errors appeared in the text of the regulations relating to program integrity for the Medicare and State health care programs. As a result, we are making corrections to two sections addressing the length of exclusion and notice of intent to exclude in order to assure the technical correctness of these regulations.

Health care programs: fraud and abuse; revised OIG exclusion authorities resulting from Public Law 104-191--OIG. Final rule.

This final rule addresses revisions to the OIG's administrative sanction authorities to comport with sections 211, 212 and 213 of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, along with other technical and conforming changes to the OIG exclusion authorities set forth in 42 CFR parts 1000, 1001, 1002 and 1005. These revisions serve to expand the scope of certain basic fraud authorities, and revise and strengthen the current legal authorities pertaining to exclusions from the Medicare, Medicaid and all other Federal health care programs.

Health care programs: fraud and abuse; revised OIG sanction authorities resulting from Public Law 105-33--OIG. Notice of proposed rulemaking.

This rulemaking proposes revisions to the OIG's exclusion and civil money penalty authorities set forth in 42 CFR parts 1001, 1002 and 1003, resulting from the Balanced Budget Act of 1997, Public Law 105-33. These proposed revisions are intended to protect and strengthen Medicare and State health care programs by increasing the OIG's anti-fraud and abuse authority through new or revised exclusion and civil money penalty provisions.

Health care programs: fraud and abuse; revised OIG civil money penalties resulting from the Health Insurance Portability and Accountability Act of 1996--Office of Inspector General (OIG), HHS. Notice of proposed rulemaking.

This proposed rule would revise the OIG's civil money penalty (CMP) authorities, in conjunction with new and revised provisions set forth in the Health Insurance Portability and Accountability Act of 1996. Among other provisions, this proposed rulemaking would codify new CMPs for: Excluded individuals retaining ownership or control interest in an entity; upcoding and claims for medically unnecessary services; offering inducements to beneficiaries; and false certification of eligibility for home health services. This rule would also codify a number of technical and conforming changes consistent with the OIG's existing sanction authorities.

Avoiding Medicare fraud. Part 1.

In 1997, Congress authorized payments to nurse practitioners (NPs) for Medicare-provided services. NP services are now reimbursed at 85% of the physician fee schedule. As this source of reimbursement was realized, so was a new area of liability for NPs. Failure to follow billing rules can result in payment denial, repayment of fees already paid, mandated educational activities, fines, fraud prosecution, loss of Medicare-billing ability, and loss of employment. Appropriate billing entails adhering to guidelines for selecting procedure codes and proper medical documentation. This article identifies high-risk areas for NPs who bill Medicare and provides resources for accessing additional information.

Coping with reduced cost limits for home health agencies.

The Omnibus Budget Reconciliation Act of 1993, together with cost-limit reductions and wage-index changes published in the Federal Register, have resulted in a substantial reduction in Medicare cost limits, particularly as they apply to hospital-based home health agencies. This article examines specific changes in home health agency cost limits, reviews strategies to identify the bottom-line impact of the Medicare cost-limit reductions, and discusses methods that may be applied to minimize the negative impact of the reduced cost limits.

Accept a substitute. But make sure to file claims for locum tenens services appropriately.

With the rapid growth of the locum tenens industry, it's increasingly important to know how to bill Medicare for locum tenens' services. The author describes when physicians and medical practices may bill Medicare for locum tenens' work and the sanctions they face for improper billing.