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

Reimbursement News

CMS Seeks Info on a Direct Provider Contracting Model for Medicare

April 24, 2018 - CMS is seeking comments on a potential alternative payment model that would allow primary care providers to directly bill Medicare beneficiaries through a direct provider contracting model. Currently, providers must opt out of Medicare for two years if they enter private contracts to deliver covered services to Medicare beneficiaries. Providers who opt out do not receive reimbursement for...


AMA, ASAM Create Alternative Payment Model for Opioid Use Disorder


The American Society of Addiction Medicine (ASAM) and the American Medical Association (AMA) recently unveiled an alternative payment model that aims to improve care and reduce costs associated with opioid use disorder. The new alternative payment...

CMS Appeals Ruling on Changing Medicaid DSH Payment Rules in MO


CMS is appealing a recent federal court decision that barred the agency from enforcing a 2017 final rule and two sub-regulatory articles from 2010 in Missouri. The federal agency stated that rule and articles clarified the formula for calculating...

Bundled Payments with Drug Costs Threaten Cancer Care Quality


Oncology bundled payments that include drug costs would negatively impact cancer care, a new report in the Journal of Oncology Practice showed. According to the report done by Milliman, Inc. for the American Society of Clinical Oncology (ASCO),...

HHS, DoJ Recovered $2.6B from Healthcare Fraud Schemes in 2017


For every dollar the federal government spent on combatting healthcare fraud and abuse in the last three years, the government recovered $4, HHS recently reported. While federal healthcare fraud investigations returned a significant amount of...

MedPAC Suggests Cutting Medicare Reimbursement for Stand-Alone EDs


The Medicare Payment Advisory Commission (MedPAC) recently voted to reduce Medicare reimbursement by 30 percent for off-campus stand-alone emergency departments (ED) in urban areas. The recommendation will be included in the commission’s...

Medical Billing Complexity Highest for Medicaid Fee-for-Service


Medical billing for Medicaid fee-for-service claims proved to be the most complex across all insurers. The public payer had a claims denial rate 17.8 percentage points greater than the rate for Medicare fee-for-service claims, a new Health Affairs...

Site-Neutral Medicare Reimbursement Too Low for LTCHs, AHA Argues


Site-neutral Medicare reimbursement for long-term care hospitals (LTCHs) will cover less than half the actual costs of care for qualifying cases, the American Hospital Association (AHA) recently told CMS. The Bipartisan Budget Act of 2013 included...

Bringing Profee, Facility Together to Maximize Coding Productivity


Professional and facility coding describe two very different aspects of a healthcare. But breaking down the wall between the departments has the potential to boost coding productivity and improve clean claim rates. While professional codes primarily...

Dissecting Merit-Based Incentive Payment System Reporting


*UPDATE: CMS extended the MIPS reporting deadline to Tuesday, April 3, 2018, at 8:00 pm EDT, according to an email sent on March 29. Eligible clinicians participating in MACRA’s Merit-Based Incentive Payment System (MIPS) must submit their...

Medical Prices Grew 28% for Hospital E&M Services Since 2012


Medical prices for hospital evaluation and management (E&M) services rose 28 percent and allowed amounts increased 26 percent between May 2012 and 2017, the most recent FH Medical Price Index from FAIR Health revealed. The analysis of over...

92% of Docs Say Prior Authorizations Negatively Impact Outcomes


Physicians are reporting that prior authorizations are negatively affecting patient care, a new American Medical Association (AMA) survey of 1,000 physicians showed. Ninety-two percent of primary care and specialty physicians who provide 20 or...

Orgs Troubled by Post-Acute Care’s Role in New Bundled Payments


Long-term and post-acute care provider organizations recently voiced their concerns with the new Bundled Payments for Care Improvement (BPCI) Advanced model’s reduced role of post-acute care providers. Eliminating the post-acute care-only...

340B Hospitals Delivered $26B in Unreimbursed, Uncompensated Care


Unreimbursed and uncompensated care costs were 27.4 percent higher at Disproportionate Share Hospitals (DSH) enrolled in the 340B Drug Pricing Program in 2015 compared to non-340B acute care hospitals, according to a new analysis from L&M...

CMS Guidance to Lower Claim Denials for Inpatient Rehab Facilities


CMS recently clarified that contracted auditors should not give inpatient rehabilitation facilities claim denials solely because the services did not meet time-based therapy requirements. The guidance, which will go into effect on March 23, stated...

Large, High-Volume Hospitals Save in CJR Bundled Payments Model


Larger hospitals with greater knee and hip replacement volumes were more likely to realize cost savings under Medicare’s mandatory lower joint replacement bundled payments model, a new analysis from Penn Medicine showed. The findings, published...

AMA, Anthem Team Up to Streamline Prior Authorizations


The American Medical Association (AMA) and Anthem, Inc. recently announced that they will work together over the next year to streamline prior authorization requirements and improve the healthcare experience overall through provider and payer...

AHA, Hospital Groups Renew Call to End 340B Drug Payment Cuts


After a federal judge recently ruled that CMS can enforce cuts to 340B drug payments, the American Hospital Association (AHA) and 35 state and regional hospital associations resumed their efforts to end $1.6 billion in reimbursement reductions....

AHA Calls for Bundled Payments Delay, Reform for BPCI Advanced


Though supportive of the Bundled Payments for Care Improvement Advanced (BPCI Advanced), the American Hospital Association (AHA) recently urged CMS to delay the model’s application deadline until the federal agency provides additional information...

Hospital Cost-Shifting Increases Private Payer Payments by 1.6%


Healthcare organizations that faced Medicare reimbursement reductions under the Affordable Care Act engaged in hospital cost-shifting that resulted in 1.6 percent higher average payments from private payers, a new working paper from the National...

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