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 […]

Technical Denials in Breast Cancer: Breaking the Code

by Gail Robinson, Fotheringill & Wade, LLC Our fifth and final article in honor of Breast Cancer Awareness Month addresses the current trend among commercial payers to limit pre-authorizations to specific Common Procedure Technology (CPT) or Healthcare Common Procedure Code System (HCPCS) codes. This practice has led to an increase in technical denials for no-authorization, when the CPT/HCPCS code billed on a claim varies even slightly from the CPT/HCPCS code authorized. Issue:   With some exceptions (outlined in our prior articles), most surgical procedures and other treatments for breast cancer are covered benefits under standard commercial health plans. However, most covered surgeries and treatments also require prior authorization. If authorization is […]

Strategies to Master IMRT Denials

by Kelley Regan Costello, Fotheringill & Wade, LLC To improve cancer survival rates, the number of providers relying on the use of intensity-modulated radiation therapy (IMRT) to treat breast cancer and other forms of cancers is growing. An unwanted consequence of the increased use of IMRT is an increase in the number of denials for IMRT treatment. Issue: Often authorization requests for IMRT are denied as experimental and investigational because many of the clinical policies insurers rely on to deny IMRT claims are based on outdated clinical sources which do not account for the most recent advances in IMRT. Until insurers policies adequately (and accurately) account for the most recent […]