The federal government’s effort to penalize hospitals for excessive patient readmissions is ending its first decade with Medicare cutting payments to nearly half the nation’s hospitals.
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CGS Medical Review Quarterly Reports by Policy
Analysis of claim denials for knee orthoses HCPCS codes L1833 and L1851 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 65.52%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for AFO HCPCS codes L1902, L1906, L1971, L4396, and L4397 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 30.79%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for lumbar sacral orthosis (LSO)HCPCS codes L0457, L0637, L0648, and L0650 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 38.37%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A5500 and A5512-A5514 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 88.35%. Please click here for the top 10 reasons for claim denials.
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Announcement is the first in a series of regulations aimed at shielding patients from increased financial hardships stemming from surprise medical bills
The Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.
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The DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS codes L0631 and L0637). These findings include claims processed primarily from March 2015 through May 2015. The review involved prepayment complex medical review of 1,384 claims submitted by 423 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 582 (42%) of the claims. For the remaining 802 claims, 148 claims were allowed and 654 claims were denied resulting in a claim denial rate of 82%. The overall CDR was 81.8%. Please click here for entire report