James D. Friedman’s Post

Changes are underway in how states are handling providers’ offshoring of data under the Medicare and Medicaid programs. This article describes the October 1, 2024 changes by Arizona to further limit providers’ and payers’ offshoring options. Stakeholders should review their practices and downstream contracts to ensure compliance with the updated language and prepare for similar regulatory interest in other states. Written by John Hintz and Meghan O'Connor, CIPP/US. #medicaid #medicare #healthlaw #dataprivacy #providers https://lnkd.in/gTGKXTPx

NEMT providers, navigating Medicaid electronic billing regulations is key to compliance and operation optimization. Check out these strategies to stay updated on the latest rules and tips for success in the dynamic healthcare industry. Read more: https://lnkd.in/g8wS3-iX #NEMT #MedicaidBilling #HealthcareRegulations

The Centers for Medicare & Medicaid Services (CMS) Burden Reduction Rule, designed to streamline administrative processes in healthcare, promises significant financial implications, particularly concerning electronic prior authorizations (ePAs). As the healthcare industry transitions from manual to electronic systems, the Burden Reduction Rule aims to simplify and expedite prior authorizations, offering substantial cost savings and efficiency improvements for healthcare providers, payers, and patients. #Healthcare #Interoperability #BurdenReduction #FinancialImplications #ePA https://lnkd.in/dJnJWFpc

Dive into the intricacies of Medicare Advantage payment models! Our latest article unpacks the coding practices, intensity adjustments, and value of accurate coding in MA. Discover how these factors shape healthcare delivery and impact payments, and stay informed about the evolving landscape of Medicare reimbursement. #MedicareAdvantage #HealthcarePayment #CodingIntegrity #emedlogix #hcccoding #riskadjustmentcoding #riskadjustment #medicare #medicaid #aiinhealthcare #medicalcoding #codingintensity #healthcare #healthinsurance https://wix.to/ZwV9hAZ

In the evolving landscape of healthcare management, tensions between healthcare organizations and medical professionals have intensified, particularly concerning billing practices and reimbursement rates. Health plans—including Medicare, Medicaid, and commercial insurers—have ramped up their efforts to review and audit physicians’ billing claims, often resulting in “Request for Reimbursement.” By Mathew Levy

NEW: A federal watchdog found that Medicare Advantage insurers collected billions of dollars in dubious payments from Medicare in a single year by using home visits and medical chart reviews to diagnose patients with conditions for which they received no follow-up care.   A report released Thursday by the Office of Inspector General for the Health and Human Services Department concluded that insurers collectively received an estimated $7.5 billion in payments last year from so-called health risk assessments (HRAs) and related reviews of medical records performed in 2022. The diagnoses added during those assessments were not found in any of the patients’ other medical records that year, suggesting that they were either inaccurate or that patients did not get potentially necessary care for serious conditions, the report found. The inspector general found that a single company — UnitedHealth Group — accounted for $3.7 billion of the questionable payments, or almost half of the total. The findings mirror an investigation by STAT that found UnitedHealth Group used its unrivaled network of physicians to pack patients’ charts with diagnoses to reap larger payments from Medicare. https://lnkd.in/epbbdAUU

Attention health care providers: in the 2025 Physician Fee Schedule Proposed Rule, #CMS proposed formalizing the six-month period for investigation of an overpayment during which the 60-day overpayment refund deadline would be temporarily suspended. Learn what this means for #Medicare and #Medicaid providers in the blog post below.

Attention health care providers: in the 2025 Physician Fee Schedule Proposed Rule, #CMS proposed formalizing the six-month period for investigation of an overpayment during which the 60-day overpayment refund deadline would be temporarily suspended. Learn what this means for #Medicare and #Medicaid providers in the blog post below.

In a rare weekend action, #CMS and #HHS just announced availability of “#ChangeHealthcare /Optum Payment Disruption (#CHOPD)” accelerated payments to #Medicare Part A providers and advance payments to Part B suppliers experiencing claims disruptions as a result of the #cybercrisis. Recognizing that providers and suppliers may face significant cash flow problems from the unusual circumstances and fluid timeline for resolution, CMS is taking direct action to support the important needs of the health care sector. Well done, CMS!!! Lots more work to be done by #MA and Managed #Medicaid plans to tackle the impacts across #MedicareAdvantage Parts C/D and MCD, but this is an extremely vital component of the solution! ⭐️⭐️⭐️⭐️⭐️

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