Tag archive: cms

CMS Update – Sharp Rise in Denials for SNF Claims

CMS issued an update regarding what appears to be a sharp increase in the denial rate for Skilled Nursing Facilities (SNFs) as reported in the 2015 Comprehensive Error Rate Testing (CERT) Report. The CERT Report showed denials increasing from 6.9% reported in 2014 to 11% in 2015. What did CMS attribute as the cause of…

CMS Issues Proposed Rule to Overhaul Part B Drug Payments

The Centers for Medicare and Medicaid Services (CMS) has released a new proposed rule to reduce Medicare expenditures by changing the way it makes payments for Part B drugs. The proposal includes two phases. The first involves changing the percent of add-on to the Average Sales Price (ASP) of the drugs from 6% to 2.5%…

New Risk for Hospitals – CMS Proposes Bundled Payments for Hip & Knee Replacement Surgeries

Building upon the bundled payment demonstration programs currently underway for Medicare, the Centers for Medicare and Medicaid Services (CMS) announced a proposal for a major shift in the way hospitals will be paid for hip and knee replacements. In an effort to incentivize hospitals to encourage quality and care improvements as patients transition from surgery…

CMS Takes Action Against Aetna Inc. for Erroneously Identifying “Retail In-Network” Pharmacies

On April 2, 2015, CMS issued notice of imposition of a $1 Million civil money penalty (CMP) against Aetna for errors reported in Aetna’s pharmacy network directory. Due to this error, many Aetna enrollees presented prescriptions to their pharmacy, only to discover that the pharmacy was not in their plan. The Medicare enrollees complained to…

CMS Calls for review of “Two-Midnight” Denials

CMS has ordered the Medicare Administrative Contractors (MACs) to re-review all denied claims for admissions under the “two-midnight” rule.  The Final Rule CMS-1599-F has proven to be difficult to implement.  On 2/24/14, CMS issued new guidance, whereby CMS is waiving the timeframe for filing redetermination requests for appeals received before 9/30/14 for claims denied before…

OIG, CMS release Final Rule for the Stark Exception, Anti-Kickback Safe Harbor for Electronic Health Records (EHR) Donation

While the donation of a valuable item such as an EHR program would raise fraud and abuse concerns, exemptions under Stark Law and Anti-Kickback Safe Harbor were designed to encourage the widespread implementation of EHR  and to let smaller providers accept gifts of EHR software without violating the law or statute. The final rule for…


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