Medicare Billings, Claims and Appeals

  • Are You Eligible for a Re-Review of Past Denied Medicare Claims?

    By on May 12, 2014

    This short article provides a brief background on the Jimmo settlement followed by an overview of who is eligible for a re-review process of denied claims for skilled care, the timeline to apply, and a link for more information. Background on the Jimmo Settlement Agreement The Jimmo settlement of January 24, 2013 clarified that...

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    California Health Advocates
  • Will the Therapy You Need be Covered?

    By on March 13, 2014

    Currently Medicare limits payment for outpatient therapy services at an annual dollar amount, commonly called “therapy caps.” For example, payment for occupational therapy is capped at $1,920 for 2014. If a beneficiary needs more services than the capped amount covers, the therapist can help the beneficiary request an exception through an “exceptions process.” The...

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  • Protect Your Durable Medical Equipment Benefits ~ Be Aware of Common Scams & Report Fraud

    By on February 6, 2014

    One of the biggest “avenues” of Medicare fraud is with suppliers of durable medical equipment (DME). Last February the Centers for Medicare and Medicaid Services (CMS) reported that two-thirds of the roughly $10 billion Medicare spent on the program were “improper” payments. While some of this is fraud and some is just errors in documentation,...

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    California Health Advocates
  • Observation Status Issue Makes Evening News

    By on January 13, 2014

    The problem of beneficiaries being held in “under observation” while receiving hospital care is growing. It often leaves affected beneficiaries with unexpected, large and sometimes financially devastating bills. This is because when someone is in classified as “under observation,” the hospital bills Medicare for outpatient services instead of inpatient care, even though the care...

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  • What is a Medicare Administrative Contractor & Why Should I Care?

    By on September 26, 2013

    Are you a provider offering Medicare hospital and/or outpatient services? Are you applying to be a Medicare provider? Or are you a Medicare beneficiary filing an appeal? If you answered yes to any of the above questions, it is important you know who serves as your regional Medicare Administrative Contractor (MAC) and what a...

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  • Will Beneficiaries Bear Extra Medicare Costs Due to the Sequester?

    By on May 18, 2013

    Many people are talking about the sequester that went into effect March 1st and the myriad of cuts. While the news reports no cuts in Medicare benefits, a 2% payment cut to providers will be imposed. The assumption is that the payment cut will not affect beneficiaries, yet it is unclear if the cost...

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    California Health Advocates
  • Medicare’s Proposed Changes to Hospital Admission Rules Don’t Address Root Concerns

    By on May 8, 2013

    “Observation status” is a hot topic amongst advocates and beneficiaries and is again back in the court room. Lois Frarie, a 93 year old retired teacher in Monterey, California, was left with a $19,000 bill for her skilled nursing home care after 4 days in the hospital. How can this be? While Medicare does...

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  • Round 2 of DMEPOS Competitive Bidding Program Starts July 1st

    By on April 17, 2013

    Round 2 of Medicare’s Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) competitive bidding program starts July 1, 2013. This round expands the DMEPOS competitive bidding program to beneficiaries in 91 major metropolitan areas across the country, and adds new product categories and a mail-order competition for diabetic testing supplies. In California, Round 2...

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  • Settlement Agreement Confirms Medicare Coverage for Skilled Maintenance Services Regardless of “Improvement”

    By on February 1, 2013

    Medicare beneficiaries can no longer be denied necessary skilled maintenance services provided in the home health, nursing home or outpatient therapy settings on the basis of showing no improvement, according to a settlement agreement approved on January 24, 2013. Legally this has always been the case. Yet, in practice, thousands of Medicare beneficiaries have...

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  • Medicare’s Therapy Cap Exceptions Process Extended for 2013

    By on January 4, 2013

    Through passing the American Taxpayer Relief Act of 2012 (ATRA), Congress yet again avoided cuts to the Medicare physician fee schedule and extended the therapy caps extension process through December 31, 2013. This extension, section 603 of ATRA, means that Medicare beneficiaries who are receiving medically necessary physical therapy, occupational therapy, and/or speech language...

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    California Health Advocates

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