DecisionHealth - Medical Practice Resources’ Post

I would encourage hospital/health system revenue cycle leaders to look at: Initial Denials for Medical Necessity on Senior Plans - in particular where there was an authorization secured. Even if most are overturned on appeal, a lot of them should not be occurring at all and that time could be spent on another case. "...the final rule codified at § 422.138(c) states that if an MA organization approved the furnishing of a covered item or service through a prior authorization or pre-service determination of coverage or payment, it may not deny coverage later on the basis of lack of medical necessity and may not reopen such a decision for any reason except for good cause (as provided at 42 CFR § 405.986) or if there is reliable evidence of fraud or similar fault per the reopening provisions at § 422.616. This means that if the MA organization pre-authorized the inpatient admission, it would be a violation of § 422.138(c) to later deny payment based on a determination that the level of care was not medically necessary."

A helpful LTC tip from PharmaComplete Consulting Services ... TRUE OR FALSE It is appropriate to bill a Patient Residence Code, 04, for patients who qualify for Long Term Care Pharmacy at Home level of service. FALSE The only appropriate Patient Residence Code for Long Term Care Pharmacy at Home level of service is 01. The Patient Residence Code, 04, is to be utilized when adjudicating claims for patients who reside in an Assisted Living Facility or licensed Group Home. If you utilize 04 for an At Home patient, when you are audited, you will have to forfeit your reimbursement as well as subject that claim to DIR Fees. More at https://lnkd.in/dYEP7wS6... ‼️ Learn how to start or improve your LTC pharmacy when you join #NCPALTC Division at https://ncpa.org/ltc. #longtermcare #pharmacycompliance

CMS-1500/HCFA-1500 33 Boxes information. 1. Type of Payer 2. Patient's Name and Gender 3. Birthdate 4. Name of the Insured 5. Physical Address 6. Patient's relation to the insured 7. Insured's address 8. Patient Status 9. Other Insured Details 10. Reserved for Local Use 11. FECA Number/Insured's Policy Group 12. Patient's Signature 13. Insured's Signature 14. Date of Illness 15. Other Dates 16. Date of Incapacitation 17. Name of Referring Physician 18. Hospitalization Dates 19. Additional Claim Information 20. Outside Lab Charges 21. Patient's Diagnosis Condition 22. Medicare Resubmission Code 23. Prior Authorization Number 24. Details of Service 25. Federal Tax ID Number 26. Patient's Account Number 27. Accept Assignment 28. Total Charge of services 29. Amount Paid 30. Balance Due 31. Signature of the Healthcare Provider 32. Facility Zip Code 33. Billing Provider NPI and Taxonomy

RUMOR MILL!!! RELEASE OF CY 2025 MEDICARE PHYSICIAN FEE SCHEDULE (PFS) CMS just released the agenda for the Thursday, July 11 Physician Open Door Forum monthly call. The agenda includes a review of the 2025 Medicare Physician Fee Schedule Proposed Rule (it reads 2024 NPRM, but I think that is a typo and should be 2025 NPRM).   This seems to be an indication that the rule should be released between now (Monday, July 8) and Wednesday, July 10. #Medicare, #PFS, #PhysicianPayment

Hey Y'all! It's here! CMS published the CY 2025 Medicare Physician Fee Schedule proposed rule (2248 pages, by the way). So, the skinny on the conversion factor (CF) is that the proposed CF is 32.3562. Initially the CF for 2024 was 32.34 but Congress passed legislation that increased it to 33.2875 that went into effect on March 9th of this year. So, the proposed 2025 CF is 0.05% higher than the finalized 2024 CF but it is 2.8% LOWER than the one currently in place after the bump from Congress. Time to put in some heavy reading time........ Please share/repost if you feel others will benefit from this information. #CMS #MPFS #Medicare #medicalpractice #medicalcoding #medicalbilling #ProposedRule #CHCS https://lnkd.in/eR4jt6iM

In the growing and evolving healthcare field, providing clinical services involves many risks, responsibilities and complexities. While corporate healthcare providers and medical and allied healthcare professionals have a duty of care to their patients, the unfortunate reality is that errors, omissions and complications can occur, leading to complaints and claims. Our article discusses the common medical malpractice claims and their impacts on patients, corporate healthcare providers, and medical and allied healthcare professionals. Read the article to find out more: https://hubs.la/Q02tVsLk0 #OpportuntiesUnlocked #TheMPLC #MedicalMalpractice #MedicalProfessionalLiability #MedicalMalpracticeInsurance #MedicalNegligence #MedMal #MedNeg

Fearful that vital details may be missed in a case review? Details that can easily be overlooked but are important to a case. ......................... One of these details came up in a case I reviewed a few weeks ago. It involved a medication that was ordered for a specific diagnosis. This medication was given once, and then it was suspended, eventually discontinued, and never given again. The patient declined and ended up dying. The ordering physician was not the provider who suspended the medication and assumed this medication was still being given. The provider that suspended the medication was another consultant. This consultant was not seen anywhere else in the records. No notes. Nothing. This finding opened up a new can of worms. Who was this provider, and how were they involved in the patient's care? Were they consulting "behind the scenes" without an actual order for a consultation? (which is a whole other issue.) Did this provider communicate to the ordering physician that they suspended this medication? What was the reasoning? Was it done in error? As a nurse familiar with the EHR, I can recognize small details that may reveal questions and findings that require further investigation. These findings could make or break a case. The truth is often in the details. #legalnurseconsultant #medicalmalpracticeattorney #personalinjuryattorney #medicalmalpractice #personalinjury

#MalpracticeMyths: In the U.S., the number of personal injury claims jumped by 97% from the year before. Yet, out of more than 400,000 such cases filed each year, only 4% make it to trial. Despite these statistics, medical malpractice remains the third leading cause of death in the U.S., following heart disease and cancer. With these statistics comes myths including: 1. Claims of medical malpractice are deceptive and drive- up healthcare expenses. This is false as malpractice costs are less than 3% of overall healthcare spending. 2. Medical malpractice claims are impossible to win. This is false, yet medical malpractice cases require a very specialized team of attorneys and specialists in order to be successful. 3. Medical Malpractice Claims Are Filed Only Against Physicians. This is false as nurses, pharmacists, dentists, and other healthcare providers can also be sued for malpractice if they breach the standard of care and cause injury Understanding these myths and realizing the facts is important when considering filing for a case. Bell Law Firm is here to help you navigate your situation.

Difference Between Medicare Part A and B Medicare Part B constitutes a key component of Original Medicare, alongside Part A. While Part A focuses on hospitalizations, certain home health care, and hospice costs, Part B addresses health condition diagnosis and treatment, as well as preventive measures like flu shots and routine checkups. Additionally, Part B extends coverage to ambulance services, durable medical equipment, select outpatient prescription drugs, mental health care, and involvement in clinical research. Are you looking for ways to enhance medical billing revenues in 2024? Hop with us on a call for medical coding and billing tips we have gathered over the last two decades as a medical billing company. Call (727) 202-5429 or visit - https://lnkd.in/eMQCvvhU. #Medicare2024 #MedicarePartA2024 #MedicarePartB2024 #Medicalbillingguidelines2024 #improvemedicalbillingoutcomes #improvepracticerevenues2024 #bestmedicalbillingcompanyFlorida

Support Medicare O&P Patient-Centered Care Act Introduced in the Senate! Take 1 min https://p2a.co/rstnncx This legislation directly affects orthotic and prosthetic coverage!!! Through its three major provisions, the legislation would: prohibit “drop shipping” of custom orthoses and prostheses to Medicare beneficiaries; ensure Medicare beneficiaries can access the full range of orthotic care from one O&P practitioner rather than requiring patients to visit multiple providers when the treating orthotist or prosthetist does not have a competitive bidding contract and; ensure Medicare beneficiaries can access replacement custom-fitted and custom-fabricated orthoses when a change in their condition or clinical needs occurs. #orthoticandprostheticcoverage #Medicare O&P Patient-Centered Care Act