The United States government has been committed to curtailing fraud, waste, and abuse across the realm of federal healthcare, since the Health Care Fraud and Abuse Control (HCFAC) Program was implemented in 1997. Since the creation of the HCFAC, more than $27.8 billion dollars has been returned to the Medicare Trust Fund due to the efforts of fraud, waste, and abuse programs.

By now, most of the medical industry has made the transition to electronic health records (EHR) to store patient health information.  Most platforms have a multitude of options to contain information through tabs, templates, and working documents. Although this may create a better means of sharing and cataloging data, it also enables new functionality that that changes the role of traditional auditing.  Back in January 2014, Inspector General Daniel Levinson conducted a study to understand contractor audit practices relating to identification of improper billing practices and billing fraud (see EXECUTIVE SUMMARY: CMS AND ITS CONTRACTORS HAVE ADOPTED FEW PROGRAM INTEGRITY PRACTICES TO ADDRESS VULNERABILITIES IN EHRSOEI-01-11-00571).  The results were somewhat surprising given the technologic capabilities of the government and the push for meaningful use compliance across the US.  Bottom line, the OIG concluded that CMS contractors have adopted few practices to address EHR vulnerabilities.

On Tuesday, April 14th, the Senate overwhelmingly passed the long-awaited Medicare Access and CHIP Reauthorization Act of 2015 with a 92 to 8 vote. This vote will repeal the flawed Sustainable Growth Rate (SGR) and dispose of a 21% Medicare payment cut that was originally to take effect earlier in April. This bill was then signed into law by President Obama on Thursday, April 16th.

The 2014 Medicare Physician Fee Schedule expired on March 31st, 2015. The new Medicare rates are scheduled for implementation on Wednesday, April 1st, 2015 and propose a 21% cut in reimbursement to physicians.

Health and Human Services (HHS) has recently announced they intend to convert a majority of Medicare payments from the current fee-for-service system to a model that focuses on performance-based measurements (alternative payment models) in the next three years. This is the first time in the history of the Medicare program that HHS has set definitive goals for alternative payment models and value-based payments.

Understanding HCC’s —what are HCC’s?

Current Procedural Terminology’s (CPT) new codes for 2015 have been released and are patiently waiting to be utilized. Being able to understand the new CPT codes and modifiers pertinent to your practice will help providers obtain the proper payment for services performed. Focusing on Evaluation and Management, below are highlights of code changes, new codes, and key modifiers that are available for use in 2015.

On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Physician Fee Schedule (MPFS) updates for the 2015 implementation. Below are highlights of updates and deeper insights on what changes/updates/policy adjustments providers can expect in 2015. 

Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) will be implementing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to help further define subsets of the -59 modifier.

Clinical laboratory test billing and payment. Beginning in Calendar Year 2014, payment for most laboratory tests, except for molecular pathology tests, will be packaged under the OPPS. The general rule for OPPS Hospital is laboratory test should be reported on a 13X type of bill.