• First year of a three year transition for cost weights
• CMS proposed to base relative weights on hospital specific costs
• Operating and Capital Payments to all hospitals will increase by $3.4 billion
• Payment rates will increase by an average of 3.5% to all hospitals
• Only 2% of hospitals have a projected reduction in payment
• Certain wage indices account for these reductions
• Goals of Final Rule
• Meaningful first steps in DRG reform
• Taking steps toward more accurate payments without disrupting hospital payments
• Ensuring Medicare does not overpay for some services while underpaying for more severely ill patients
• Correcting inappropriate hospital incentives for treating certain types of patients by redirecting portions of overpayments to underpaid cases
• Key Policies for 2007
• Meaningful refinements to the current CMS classification system
• Conduct an evaluation w/ public comments of alternative severity adjustment systems for implementation in 2008
• 2007 Final Rule Impact
• Limited hospital payment impact due to simultaneous implementation of incremental reforms
• Payments will better reflect payment accuracy
• Payments will reflect costs rather than charges
• Reforms will eliminate biasis in the current system
• Limited hospital payment impact due to simultaneous implementation of incremental reforms
• 2007 Final Rule Impact on DRG
• No DRG weight will decrease more than 5.4% in 2007
• 19 DRG weights increase by more than 5% as compared to the current weight methodology in the 1st year
• 2007 Final Rule IPPS Changes
• Changes will help assure all beneficiaries have access to appropriate, high-quality care
• The Medicare Payment Advisory Commission (MedPAC) supports these reforms
• Types of payment changes being implemented were described as “promising”in a recently released Government Accountability Office (GAO) report
• Payments based on costs
• CMS proposed to base relative weights on hospital-specific costs
• Hospitals markup charges over costs bearing little relation to costs
• CMS to refine cost-based method based on public comments
• 2007 Final Rule Impact on Severity Illness
• Refinements to prevent underpayments
• CMS identified 20 new DRG’s to improve illness recognition
• 32 current DRG’s modified to better capture differences in severity
• CMS to conduct evaluation of alternative DRG severity systems
• Specialty Hospitals
• Proposed revisions to reduce incentives for hospitals to cross-subsidize
• Example: Cardiovascular DRG’S

• 5.1% decrease in payment rates
• Proposed changes to components of physician payments:
• Work component relative value units (RVUs);
• Changes for calculating practice expenses

• Payments for E/M services increase 37%
• Work Component RVUsfor an office visit requiring moderately complex decision making increase by 29%
• Payments for hospital visits requiring moderately complex decision making increase by 31%
• Expenditure increase by ~$4.0 billion
• CMS proposes 10% budget neutrality adjuster to be applied to work RVUsfor Medicare to offset expenditure increase

• “Bottom Up”method for direct costs
• Use of survey data
• Elimination of the non-physician work pool
• New method for calculating indirect practice expenses

• 25% phase in each year until 2010

• Preventive Services
• Medicare will pay for Abdominal Aortic Aneurysm (AAA) ultrasound screening beginning Jan 1, 2007
• Colorectal Cancer Screening benefit
• Long term steroid therapy and bone mass measurement eligibility
• Imaging Services
• 25% payment decrease for technical component of multiple imaging procedures on contiguous body parts
• Payment caps for multiple imaging procedures
• Proposed rules on billing Diagnostic Tests
• Reassignment and physician self-referral rules associated with diagnostic tests
• Composite payment rate for dialysis services provided by ESRD facilities
• Centralized Building/Compliance
• Self-referral regulation restrictions : space ownership/leasing arrangements that qualify for exceptions
• Work RVUsassigned to Medical nutrition therapy services:
• CPT codes 97802, 97803, and 97804
• HCPCS codes G0270 and G0271

• Payment rate increases linked to reporting of quality measures
• Payments decrease 2% for hospitals that fail to report quality measures
• Estimated 3.0% increase in Medicare payments for outpatient department services in 2007

• 14 additional surgical procedures would be added to the list of Medicare approved ASC services
• Provision of Deficit Reduction Act of 2005 (DRA) caps payment for ASC procedures in 2007 at rate paid to a hospital outpatient department

• Unit of Service Limits for more than 10,800 codes billed to Medicare
• Purpose: Prevent overpayments from the reporting of excess units of service due to errors
• Appeals process must be used to fight denials based on MUEs

• Deputy Director, Program Integrity, Office of Financial Management at CMS indicates it will not be necessary to use a modifier in order to avoid using an MUE
• Medical Instances exceeding the limit should be appealed
• CMS appeals process set up for both edits and individual claims

• Edits were sent out to specialty societies for a round of comments through Sept 25, 2006

• Comments from Oct 1 –Dec 1, 2006

• October 1, 2006:Marketing Plan Activities
• November 15 to December 31, 2006:Annual Coordinated Election Period
• No enrollment required to renew present coverage
• Medicare Part D plan effective January 1, 2007
• January 1 to March 31, 2007:Special Enrollment Period for beneficiaries enrolled in the Medicare Advantage Plan with Prescription Drug Coverage

• The new list of plans that will offer Medicare Part D drug coverage for calendar year 2007 are now available
• Some plans have already notified CMS that they will not offer coverage next year
• Insurance providers that opt to continue to participate in Part D have the option to change or raise premiums for their coverage

• AIS: Guide to the Medicare Drug Benefit: http://www.aishealth.com
• CMS "Quick Facts About Medicare Prescription Drug Coverage and Protecting Your Personal Information" : http://www.medicare.gov/Publications/Pubs/pdf/11147.pdf
• Medicare questions, verification, plan comparisons, or enrollment: call 800-633-4227 or 1-800-MEDICARE or http://www.medicare.gov
• SHIP: Local State Health Insurance Information Program offers free Medicare Part D counseling. Call Medicare at 800-633-4227 or http://www.shiptalk.org
• Area Aging Agencies: Contact the local aging agency. Call 800-677-1116

• Predicted increased audits by insurers/gov’t
• Restructuring of market with CDHPs
• Harder bargaining positions as insurers consolidate
• New insurance regs

• OIG has released the Medi-MediProgram
• DRA requires states to evaluate false claims
• DSH audits are hammering states
• Outlier actions against hospitals are up
• Premium pressures are increasing CDHPs
• NJ passes the HCAPPA
• NAIC passes SOX for insurers

• Created by DRA
• Similar to the MIP
• Detect & prevent Medicaid fraud
• CMSO to design fraud and abuse programs
• MIP Contractors will be used in conjunction with gov’tworkers

• Principles
• Nat’l Leadership
• Accountability
• Collaboration
• Flexibility
• Functions
• Create CMIP
• Procure/oversee MICs
• Field Operations
• Fraud Research and Detection
• Congressional 4/07, funding to increase 12M/yr thru 2010

• States encouraged to pass false claims acts similar to OIG
• 10% bonus collection
• Law must contain:
• Whistleblower
• 60 day AG review
• Treble damages

CDHP’sGaining Momentum Employer costs up Trends show no signs of breaking Pressure to keep competitive Industry Talent Pool

Average Annual Premiums and Contributions to Spending Accounts For Singles/ Families Covered in HSA Qualified HDHPsCompared to All Plans, 2005 (Source HRET 2005 Study)

• United Healthcare taking tough positions in market place
• Medicaid and Medicare spending will be below healthcare inflation rates
• Pay for performance is showing up in more contracts, paradigm shift?

• MSA’sand MH Parity extended (HR 5970)
• MSAswill expire in 12/07
• Mental Health Parity Act extended thru 12/07 for GHP’s>50
• Tax Reform? (Breaux
• Proposed limit to employer HP deductions
• 06 $5000 single, $11,500 family
• “Save for Family Accounts”
• State-Based HC Reform (Feingold S 3776)
• $32B over 10 years
• Help states implement ‘Universal Healthcare”
• Benefits similar to FEHBP

• Enacted 1/12/06, effective 7/11/06
• Many providers unaware or not prepared to implement
• Amends HCQA with respect to IHCAP Program
• Covered person (CP) may now give consent prior to service
• Consent valid through all levels of appeals
• Provider must notify CP in writing at each stage of the appeal
• CP may revoke consent at any time by writing the provider
• Valid only for DOS 7/11/06 and beyond
• Forms are available, see Bulletin 06-16
• 90 statutory timeframe for filing appeal continues to apply
• If a provider disagrees with a final appeal decision, they can apply for arbitration
• Establishes an Arbitration Organization “AO”to hear single or multiple claim issues
• Statute of Limitations does not apply until AO contract is awarded

• Codes are effective 10/1/06 with no grace period
• 211 New Diagnosis Codes
• 55 Revised Codes
• 29 Deleted (invalid) Diagnosis Codes

• Infectious & Parasitic Diseases—3 New Codes
• 052.2Postvaricella Myelitis
• 053.14 Herpes ZosterMyelitis
• 054.74 Herpes SimplexMyelitis

• Neoplasms—Hematologic Malignancies—7 New Codes
• Essential thrombocytopenia
• MyelodysplasticSyndrome Codes
• Myelofibrosis

• Endocrine, Nutritional and Metabolic, Immunity —3 New Codes
• Amyloidosis
• Familial Mediterranean Fever
• Other Amyloidosis

• Blood and Blood Forming Organs–23 New Codes
• Aplasticanemia and white blood cell disorders expanded
(284.01, 284.09, 284.1, 284.2. 288.00 –288.69)
• Neutropenic splenomegalyandMyelofibrosis(289.53, 289.53)
• Nervous System & Sense Organs–40 New Codes
• Separate Codes for Encephalitis/Encephalomyelitis andMyelitis(323.01-323.82)
• Mild cognitive impairment, so stated (331.83)
• Athetoidcerebral palsy (333.71)
• Acutedystoniadue to drugs (333.72)
• Other acquired torsiondystonia(333.79)
• Subacute dyskinesiadue to drugs (333.85)
• Restless Legs syndrome (333.94)
• Pain syndromes (338.0-338.4)
• Myelitis(341.20 –341.22)
• Optic nervehypoplasia(377.43)
• Inflammation ofpostproceduralbleb (379.60 –379.63)
• Sensorineuralhearing loss unilateral and asymmetrical (389.15 –389.16)
• Circulatory System –1 New Code
• TakotsuboSyndrome (429.83)
• Respiratory System -5 New Codes
• Nasalmucositis(478.11)
• Other diseases of nasal cavity (478.19)
• TRALI (Transfusion related acute lung injury) –518.7
• Acutebronchospasmwithout Asthma DX-(519.11)
• Other diseases of the trachea and bronchus
• Digestive System –31 New Codes
• Cracked tooth (521.81)
• Other specific diseases of hard tissues of the teeth (521.89)
• Acute and Chronic gingivitis (523.00 –523.11)
• Aggressive, Acute and Chronicperiodontitis(523.30 –523.42)
• Dental restorations –repairs,fractures, and complications (525.60 –525.69)
• Perforation of root canal space (526.61)
• Endodontic over fill and under fill (526.62 –526.63)
• Otherperiradicularpathology (526.69)
• StomatitisandMucositis(528.00 –528.09)
• GastrointestinalMucositis( 538)
• Genitourinary System –11 New Codes
• Torsion of testis and spermatic cord (608.20 –608.24)
• Mucositiscervix, vagina and vulva (616.81)
• Other inflammatory disease of cervix, vagina, and vulva (616.89)
• Cervical stumpprolapse(618.84)
• Other female mutilation status (629.29)
• Other specified disorders of female genital organs (629.89)
• Complications of Pregnancy, Childbirth andPuerperium–33 New Codes
• Tobacco Use Complicating (649.00 –649.04)
• Obesity Complicating (649.10 –649.14)
• Bariatric Surgery Status Complicating (649.20 –649.34)
• Coagulation Disorders Complicating (649.30 –649.34)
• Epilepsy Complicating (649.40 –649.44)
• Spotting Complicating (649.50 –649.53)
• Uterine size discrepancy (649.60 –649.64)
• Musculoskeletal System and Connective Tissue –5 New Codes
• Nontraumaticcompartment syndrome (729.71 –729.79)
• Major Osseous Defects (731.3)
• Conditions in thePerinatalPeriod –6 New Codes
• Hypoxic-ischemic encephalopathy HIE (768.7)
• Respiratory Arrest of newborn (770.87)
• Hypoxemia of newborn (770.88)
• Other acidosis of newborn (775.81)
• Other neonatal endocrine and metabolic disturbances (775.89)
• Cardiac Arrest of newborn (779.85)
• Symptoms, Signs, and Ill-Defined Conditions —13 New Codes
• Complex febrile convulsions (780.32)
• Generalized pain (780.96)
• Altered mental status (780.97)
• Postnasal drip (784.91)
• Other symptoms involving head and neck (784.99)
• Urinary hesitancy (788.64)
• Straining on urination (788.65)
• Image test inconclusive due to body fat (793.91)
• Other nonspecific abnormal findings on radiological and other examinations of body structure
• Pap smear of cervixcytologicwith evidence of malignancy
• Elevatedcarcinoembryonicantigen –CEA (795.81)
• Elevated cancer antigen 125 –CA 125 (795.82)
• Other abnormal tumor markers (795.89)
• Injury and Poisoning –11 New Codes
• Compartment syndrome (958.90 –958.99)
• Unspecified adverse effect of unspecified drug, medicinal and biological substance (995.20)
• Arthusphenomenon (995.21)
• Unspecified adverse effect of anesthesia (995.22)
• Unspecified adverse effect of insulin (995.23)
• Unspecified adverse effect of other drug, medicinal and biological substance (995.29)

• Family history of colon polyps (V18.51)
• Family history of other digestive disorders (V18.59)
• Testing of male for genetic disease carrier status (V28.34)
• Encounter for testing of male partner of habitualaborter(V26.35)
• Other genetic testing of male (V28.39)
• Bariatric surgery status (V45.86)
• Encounter for change or removal of non-surgical dressing (V58.30)
• Encounter for change of surgical dressing (V58.31)
• Encounter for removal of sutures (V58.32)
• Encounter for hearing examination following failed hearing screening (V72.11)
• Other examination of ears and hearing (V72.19)
• Screening for genetic disease carrier status (V82.71)
• Other genetic screening (V82.79)
• Body mass index (V85.51 –V85.54)
• Estrogen receptor positive status-ER+ (V86.0)
• Estrogen receptor negative status-ER-(V86.1)

• Anesthesia –2 New Codes; 1 Deleted Code
• Integumentary–21 New Codes; 16Deleted Codes
• Surgical prep or creation of recipient site by excision of open wounds, burn or scar (including subcutaneous tissues), or incisional release of scar contracture
• 4 Codes –Based on site and size
• Moh’s Micrographic Technique
• 5 New Codes (17311 –17315)
• 5 Deleted Codes (17304 –17307 and 17310)
• Mastectomy
• 8 New Codes (19300 –19307)
• 8 Deleted Codes (19140, 19160, 19162, 19180,1982, 19200, 19220 & 19240)
• Musculoskeletal —13 New Codes; 7 Deleted Codes
• Percutaneous intradiscal electrothermal annuloplasty
• Total disc arthroplasty; Revision; Removal
• Excision of tendon, forearm and/or wrist
• Percutaneous skeletal fixation of distal radial fracture (fx)
• New Codes: 25606 Deleted Code: 25611
• Open treatment of distal radial fx
• New Codes: 25607 –25609
• Deleted Code: 25620
• Neurectomy
• New Codes: 27325, 27326 &7 28055
• Deleted Codes: 27315, 27320 & 28030
• Respiratory –1 New Code; 3 Deleted Codes
• Cardiovascular –26 New Codes; 10 Deleted Codes
• Insertion of epicardial electrode(s)
• Operative tissue ablation & reconstruction of atria
• Endoscopy, surgical; operative tissue ablation & reconstruction of atria
• Closure of multiple ventricular septal defects
• Repair of pulmonary venous stenosis
• Thromboendarectomy
• 5 New Codes: 35302-35306
• Deleted Code: 35381
• Bypass Graft
• 6 New Codes: 35537 –35540; 35637 –35638
• 4 Deleted Codes: 35507; 35541; 35546 & 35641
• Uterine fibroid embolization
• New Code: 37210
• Digestive –15 New Codes; 6 Deleted Codes
• Neurostimulator Electrodes
• Laparoscopy; Implantation; Revision; Removal
• Colectomy, total, abdominal, with proctectomy
• New Codes: 44157 & 44158
• Deleted: Colectomy, total, abdominal without proctectomy –44152 & 44153
• Anastomosis, choledochal cyst, without excision
• New Code: 47719
• Deleted Code: 47716
• Resection or debridement of pancreas & peripancreatic tissue for acute necrotizing pancreatitis
• New Code: 48105 Deleted Code: 48005
• Pancreaticojejunostomy
• New Code: 48548 Deleted Code: 48180
• Removal of peritoneal foreign body from peritoneal cavity
• New Code: 49402 Deleted Code: 49085
• Male Genital System –3 New Codes; 3 Deleted Codes
• Female Genital System –10 New codes; 1 Deleted Code
• Hymenotomy, Simple incision
• New Code: 56442 Deleted Code: 56720
• D & C of Cervical Stump
• New Code: 57558 Deleted Code: 57820
• Laparoscopy, surgical, supracervical hysterectomy
• New Codes: 58541 –58544
• Laparoscopy, surgical with radical hysterectomy -58548
• Nervous System –2 New Codes
• Eye & Ocular –1 New Code; 1 Deleted Code
• Biopsy of extraocular muscle
• New Code: 67346 Deleted Code: 67350
• Radiology –46 New Codes; 41 Deleted Codes
• MRI of brain –70554 & 70555
• Ultrasound, pregnant uterus –76813 & 76814
• Ultrasonic guidance, intraoperative –76998
• CT guidance for sterotactic localization -77011
• CT guidance for needle placement –77021 (Deleted: 76360)
• Stereotactic localization guidance for breast biopsy or needle placement –77031 (Deleted: 76095)
• Mammography; unilateral –77055 (Deleted: 76090)
• Mammography; bilateral –77056 (Deleted: 76091)
• Screening Mammography; bilateral –77057 (Deleted: 76092)
• Bone Density Studies
• Dual-energy x-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg. Hips, pelvis, spine)
• New Code: 77080Deleted Code: 76075
• DXA, bone density study, 1 or more sites; appendicular skeleton (eg. Radius, wrist, heel)
• New Code: 77081Deleted Code: 76076
• DXA, bone density study, 1 or more sites; vertebral fracture assessment
• New Code: 77082Deleted Code: 76077
• Pathology/Lab —11 New Codes
• Medicine —20 New Codes; 5 Deleted
• Ventilation Assist and Management
• Initial Day, Hospital —
• New: 94002 Deleted: 94656
• Subsequent Day, Hospital
• New: 94003 Deleted: 94657
• Nursing Facility, Per Day —New Code: 94004
• Home Ventilator Management Care Plan Oversight of a Patient –New Code: 94005
• Continuous inhalation treatment with aerosol medication for acute airway obstruction
• First Hour –94644
• Each Additional Hour 94645
• Pediatric Home Apnea Monitoring Event Recording
• Codes 94774 —94777
• Medical Genetics & Genetic Counseling Services, each 30 minutes face-to-face with patient/family —
• Code 96040
• Category II Codes —1 Deleted Code
• 2003F —Auscultation of the heart performed
• Category III Codes —16 New Codes; 9 Deleted Codes

Welcome to Medicare Exam New Service
• Abdominal Aortic Aneurysm (AAA) Screenings
• Must be referred as a result of the Welcome to Medicare Exam
• Medicare has never paid for a screening for the patient
• Patient has any of the following risk factors
• Family history of AAA
• Male between 65 & 75 who has smoked at least 100 cigarettes in his life
• Any other subsequent criteria recommended by the US Preventive Services Task Force
• CMS proposes creating a new G code with the description:
• Ultrasound, B-scan and/or real time with image documentation; for AAA screening
• Will be reimbursed the same amount as for the CPT code used for diagnostic tests —76775
• 2006 Reimbursement —$87.16
• The task force specifically recommends that women are not routinely screened for AAA
• “Important harms, including an increased number of surgeries with associated morbidity and mortality, and psychological harms outweigh the benefits”

• Medical DRG weights will increase by 7.3%
• Surgical DRG weights will decrease by 6.9%

• Hospital Outpatient Setting
• CMS states the current model of physician-based CPT codes is not appropriate for use in the hospital setting
• 17 New HCPCS “G”Codes
• Five to report hospital clinic visits
• Five to report emergency department (ED) visits provided by a hospital outpatient ED that meets the definition of an ED (open 24 hours, seven days per week)
• Five to report ED visits by a dedicated (DED) defined as not always open after hours but still meeting EMTALA and other criteria
• Two to report critical care

• Maximum payment for clinic visits would increase from $92 to $133
• ED visits would increase from a current maximum of $244 to $345

• CMS will now pay separately for the initial infusion codes as well as additional hours add-on codes for both chemotherapy and non-chemotherapy services
• There will be the addition of six new drug administration APC’s

• The median cost of less than $50 considered packaged will be increased to less than $55

• Decrease from the current model of average sales price (ASP) +6% down to ASP +5%

• Six “Special Package”Codes
• Separate APC payment for these services when reported on a date of service with no other separately payable OPPS service
• CPT Codes
• 36540 –Collection of blood specimen from a completely implantable venous access device
• 36600 –Arterial puncture, withdrawal of blood for diagnosis
• 38792 –Injection procedure; lymphangiography for identification of sentinel node
• 75893 –Venous sampling with or without angiography, radiological supervision and interpretation
• 94762 –Noninvasive ear or pulse oximetry of O2 saturation by continous overnight monitoring
• 96523 –Irrigation of implanted venous access device for drug delivery systems

• The proposed 2007 OPPS rule would add 14 surgical procedures to the list for Medicare reimbursement ASC’s in 2007
• Codes, Description, ASC Payment Group
• 13102 Repair wound/lesion add-on (1)
• 13122 Repair wound/lesion add-on (1)
• 13133 Repair wound/lesion add-on (1)
• 19297 Place breast cath for radiation (9)
• 21356 Treat cheek bone fracture (3)
• 22520 Percutaneous vertebroplasty, thoracic(9)
• 22521 Percutaneousvertebroplasty lumbar (9)
• 22522 Percutaneous vertebroplasty, additional(1)
• 35476 Repair venous blockage (9)
• 36818 AV fuse, upper arm, cephalic (3)
• 37205 Transcath IV stent, percutaneous (9)
• 37206 Transcath IV stent/perc, add’l (1)
• 43761 Reposition gastrostomy tube (1)
• 46946 Ligation of hemorrhoids (1)

• HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans, must use only the NPI to identify covered healthcare providers in standard transactions by May 23, 2007
• How to apply:
• Web applications: https://nppes.cms.hhs.gov
• Download applications & mail to: NPI Enumerator, PO Box 6059, Fargo, ND 58108-6059
• Phone Contact: 800-465-3203

• Wound Care
• Review whether claims for wound care services were medically necessary ∓ will examine the controls preventing improper payments for these services
• “Incident-to”Services
• Appropriateness of Medicare services performed “incident-to”the professional services of physicians ∓ will determine whether the services met the standards for medical necessity, documentation & quality of care

• Medicare’s Assignment Rules
• Review whether patients are being billed more than the Medicare allowable for services. OIG will examine whether patients are aware of their rights should they be overcharged
• Use of Imaging Services in Physician Offices
• Growth of imaging services in physician offices
• Billing patterns in geographic regions & practice settings
• Polysomnography Tests (Sleep Studies)
• Review whether sleep studies are billed appropriately to Medicare
• 2001 Medicare Payments -$62 Million
• 2004 Medicare Payments -$170 Million
• Pathology Services in Physician Offices
• More than $1 billion in annual Medicare payments
• Relationships between physicians who provide services in their offices & outside pathology companies
• Eye Surgery
• Review whether cataract and laser eye surgeries are being billed correctly
• Billing Services
• How relationships between medical practices and billing companies may affect your billing
• Cardiography/Echocardiography
• Review whether practices correctly bill for the technical & professional components
• Welcome to Medicare Exam Payment
• Review whether Initial Preventive Physical Exam (IPPE) payments for existing practice patients who are new to Medicare are a wise expenditure of Medicare dollars
• IPPE pays a higher payment for work that could have been done on a previous E/M visit
• PT/OT Services
• To determine if services were medically necessary, documented correctly & certified by physicians
• Botox Treatments
• Check for billing abuse
• Medicare pays for certain spastic conditions but not to erase wrinkles

• Inpatient Rehabilitation Facility (IRF) Classification Criteria
• Review of the extent of admissions to IRF’s & whether they meet specific regulations & whether the facilities billed for services in compliance with Medicare rules
• Medical Appropriateness & Coding of DRG Services
• To identify providers who exhibit high or unusual patterns for certain DRGs by reviewing inpatient hospital claims. The reviews will determine medical necessity, appropriate level of coding and reimbursement for a sample of services billed by the providers.
• IRF Compliance with Medicare Requirements
• Review of payments to IRF’s under the prospective payment system & whether they were made in accordance with Medicare rules, including whether a claim paid as a discharge should have been paid as a transfer, and outlier claims.
• Oversight of Specialty Hospitals
• Review CMS’s oversight of physician-owned specialty hospitals to ensure patient safety and quality of care. The review will include examination of policies on staffing requirements
• “Inpatient Only”Services Performed in an Outpatient Setting
• Determine if Medicare payments are appropriately denied for “inpatient only & related services performed in an outpatient setting and assess the extent to which Medicare beneficiaries are held liable for denied inpatient claims for these services.