Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid


60% of RAC Reviewed Claims Showed No Medicare Overpayments

by Jacqueline Belliveau

Reducing healthcare fraud, waste, and abuse has recently been on the top of the CMS agenda, but some healthcare providers are questioning how effective some CMS initiatives are at identifying potential Medicare overpayments. The American Hospital...

OIG: CMS Lacked Good Management Policies for Pioneer ACO Model

by Jacqueline Belliveau

The Pioneer Accountable Care Organization (ACO) program faced a number of management and leadership challenges during its early days, according to a report from the Office of the Inspector General (OIG).  The report indicates CMS faced several...

Medicare Shared Savings Program Gets New Cost Calculations

by Jacqueline Belliveau

The Centers for Medicare and Medicaid Services (CMS) has recently finalized a rule that will change the methodology for calculating costs under Medicare Shared Saving Program, the federal agency announced. MSSP accountable care organizations...

CMS Allows Some ACOs to Join New Value-Based Care Model

by Jacqueline Belliveau

CMS has expanded the eligibility requirements in the Comprehensive Primary Care Plus (CPC+) model to include primary care physicians in certain Medicare accountable care organizations (ACOs), according to an updated fact sheet. Up to 1,500 primary...

Big Data Tool Saves CMS $1.5B by Preventing Medicare Fraud

by Jacqueline Belliveau

Using big data tools and predictive analytics, the Centers for Medicare and Medicaid Services (CMS) has saved approximately $1.5 billion by preventing Medicare fraud in the traditional fee-for-service program, according to the official CMS blog....

Congress Asks CMS to Scrap Prior Authorization for Home Health

by Catherine Sampson

A CMS proposal to require a prior authorization screening for every home health service would be an administrative nightmare and may produce barriers to care for needy patients, a group of 116 lawmakers said in a letter to CMS this week. "This...

GAO: Weak Medicare, Medicaid Provider Screening Allows Fraud

by Catherine Sampson

The Centers for Medicare & Medicaid Services’ (CMS) provider enrollment screening process is vulnerable to fraud because many ineligible providers are still being entered into the Provider Enrollment, Chain and Ownership System (PECOS),...

Newly Launched MACRA Initiative Aims to Support Providers

by Catherine Sampson

On May 25, American Medical Group Association (AMGA) launched a resource to help its members prepare for MACRA implementation as well as all risk-based payment systems. “We are making it our priority to ensure our members have the tools...

OIG: CMS Not Reducing Medicare, Medicaid Improper Payments

by Catherine Sampson

In testimony submitted to House of Representatives Subcommittee on Oversight and Investigations, the Office of Inspector General (OIG) urged the Centers for Medicare & Medicaid Services to work with states to correct gaps in their...

Providers Spend $15.4B to Report on Healthcare Quality Measures

by Catherine Sampson

General internists, family physicians, cardiologists, and orthopedists spend more than $15.4 billion annually to report on healthcare quality measures set by payers, according to a report from Health Affairs. Annually, these four types of practices...

CPC Initiative Improves Care Delivery But Not Medicare Spending

by Catherine Sampson

Although the Comprehensive Primary Care (CPC) initiative lead to progress in primary care delivery, it has not caused improvements in Medicare spending, patient experience or quality of care, researchers from The New England Journal of Medicine...

AHA: MACRA Alternative Payment Model Incentives Need Changing

by Catherine Sampson

The MACRA Alternative Payment Model incentives should be implemented in a way that provides the best opportunity for physicians to become qualifying participants, the American Hospital Association argued in a letter to CMS this week MACRA provides...

GAO: Millions Spent Yearly on Ineligible Medicaid Reimbursements

by Catherine Sampson

Ineligible managed care providers currently receive $3 million in Medicaid reimbursements annually, the Government Accountability Office (GAO) said in a report, due to the lack of effective screening processes. “The integrity of the Medicaid...

Providers Collect More Revenue Due to ACA Medicaid Expansion

by Catherine Sampson

In recent years, the Affordable Care Act (ACA) paved the way for significant Medicaid expansion. A recent study from the National Bureau of Economic Research found that Medicaid expansion resulted in financial benefits for low-income patients...

How MACRA, MIPS Will Impact Critical Access Hospitals, FQHCs

by Catherine Sampson

MACRA means different things to various types of healthcare providers, such as critical access hospitals, rural health clinics and Federally Qualified Health Centers. Although the new MACRA framework provides multiple paths to success with various...

Top 5 Facts to Know about MACRA Alternative Payment Models

by Catherine Sampson

CMS recently proposed a rule that would put last year's MACRA's legislation into action. The proposal introduces several significant changes to the way providers will attest to quality improvements and technology use, but also includes...

Number of Accountable Care Organizations Continue to Rise

by Catherine Sampson

The number of accountable care organizations (ACOs) continue to increase across the county. Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced 121 new Medicare Accountable Care Organization (ACO) participants. Between...

CMS Payment Reforms Mean Big Bucks for Medicare, Medicaid

by Catherine Sampson

Over the past month, CMS has announced finalized and proposed rules that would significantly impact payment policies in 2017 for managed care in Medicaid and the Children’s Health Insurance Program (CHIP) as well as Medicare hospice benefits,...

CMS Plans to Reverse Two-Midnight Rule for Medicare Payments

by Catherine Sampson

On April 18, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that addresses the problematic two-midnight rule that produced 0.2 percent payment reductions for certain hospital inpatient services. The new rule would...

CMS Extends Application Period for Next Generation ACO Model

by Catherine Sampson

Providers interested in participating in the Next Generation Accountable Care Organization (ACO) program now have until May 20, 2016 to submit their letters of intent, CMS announced this week. In order to apply to the Next Generation ACO Model,...


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