CMS proposes removing total knee replacements from inpatient-only list

In the 2018 OPPS proposed rule, CMS is moving ahead with a proposal to remove total knee replacements under CPT code 27477 (arthroplasty, knee, condyle and plateau; medial and lateral components with or without patella resurfacing (total knee arthroplasty)) from the inpatient-only list. If finalized, the procedure would be added to comprehensive APC (C-APC) 5115 (Level 5 Musculoskeletal Procedures) and assigned status indicator J1 (hospital Part B services paid through a C-APC). The agency solicited comments from the public on whether total knee arthroplasty (TKA) should be removed from the inpatient only list in the 2017 OPPS proposed rule. In making the decision to officially propose removal of TKA from […]

“Grace Period” Coverage Under Exchange Plans: How Federal Regulations Can Alter Eligibility Determinations for Providers

By Matthew Horton, Fotheringill & Wade, LLC The Affordable Care Act (ACA, or commonly referred to as Obamacare) altered the landscape for individual and small group insurance plans. ACA altered this market with two important provisions: (1) the creation of Qualified Health Plans (QHPs, also referred to as Exchange Plans) and (2) establishing Exchanges (also called health care marketplaces), such as the Federal Exchange, Healthcare.gov. With the creation of QHPs under the ACA, there are a litany of new federal requirements health insurers must follow; one such requirement is the “grace period,” and providers should be aware if a patient is in the grace period because of the potential for […]

CMS Issues Proposed Updates to the “Two-Midnight” Rule

On July 1, 2015, CMS released proposed updates to the “Two-Midnight” rule regarding when inpatient admissions are appropriate for payment under Medicare Part A.  The proposed updates were included in the calendar year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) proposed rule.  As per the fact sheet, CMS is: Proposing to change the standard by which inpatient admissions generally qualify for Part A payment based on feedback from hospitals and physician to reiterate and emphasize the role of physician judgment Announcing a change in the enforcement of the standard so that Quality Improvement Organizations (QIOs) will oversee the majority of patient status audits, with the Recovery Audit program focusing […]

CMS Presolicitation Notice: Unified Program Integrity Contract (UPIC)

On June 5, 2015 CMS issued a presoliciation notice indicating that they will be issuing a Request for Proposal (RFP) to solicit services for the Unified Program Integrity Contract (UPIC).  As per the notice, “the UPIC will combine and integrate existing CMS program integrity functions carried out by multiple contractors and contracts into a single contractor to improve its capacity to swiftly anticipate and adapt to the ever changing and dynamic nature of those involved in health care fraud, waste, and abuse across the Medicare and Medicaid program integrity continuum.” The solicitation will be available on or about June 22, 2015, and will be distributed solely through the Federal Business […]

Zone (Program Integrity Contractor) Defense: Successfully Navigating ZPIC Audits

Sarah Mendiola, Esq., Linda Fotheringill, Esq., Fotheringill & Wade, LLC While the provider community has been focusing on combating denials from the RACs and MACs, audits by the Zone Program Integrity Contractors (ZPICs) have been quietly recovering hundreds of millions of dollars in identified overpayments. If you talk to a provider who has been involved in a ZPIC audit, you will quickly realize that this type of audit can be devastating in its impact.  This paper explains why the ZPIC is not your typical Medicare auditor and what a provider can do to potentially minimize the impact of a ZPIC audit on their organization. Issue: ZPICs are looking for “fraud […]