The Medicare Appeals Process – Review of Ophthalmology

Appealing a claim can be daunting. Here’s how to navigate the process, should you need to make an appeal. This article addresses the following questions: One of my Medicare claims was denied and now I need to appeal. How does the Medicare Appeals process work? I found out I have to appeal something formally.  What’s…

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Medicare Provider Revalidation

Be On the Lookout! Medicare requires that you revalidate enrollment for each provider every 5 years, and for DMEPOS suppliers (optical) every 3 years.  CMS is supposed to send you a notice when it is time to revalidate.  Tell your staff to be sure to watch for this. Several of our clients have failed to…

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Orders for Diagnostic Testing – Ophthalmic Professional

Here’s a fairly common scenario for technicians: Mrs. Jones, a patient, has complaints of decreased vision that does not improve with a careful refraction. The technician reads the chart and, based on one of the patient’s previous diagnoses, “knows” the doctor will want an OCT of the retina. Is this proper? Can the practice bill…

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CMS Releases 2014 Payment Data

Earlier this week, CMS posted the Medicare provider utilization and payment data from 2014.  The release of annual data began in 2014 as part of President Obama’s “transparency” initiative.  When the 2012 data was released in 2014, it created headlines and major news stories.  Ophthalmology was targeted aggressively since the provider with the highest reimbursements…

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CMS Limits Scope of Review on Some Redeterminations and Reconsiderations

The Centers for Medicare and Medicaid Services (CMS) issued a revision on May 9, 2016, to a Special Edition of MedLearn Matters (SE1521 Revised).  It deals with a new limit placed on the amount of discretion CMS will allow to Medicare Administrative Contractors (MACs) at the first-level appeals (Redetermination).  Importantly, CMS noted in this document…

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Provider Enrollment Validation – Cycle 2

The Centers for Medicare and Medicaid Services (CMS) require that providers periodically revalidate their enrollment in Medicare. On April 18, 2016, CMS announced that they had completed the initial round of revalidations. The first of the “Cycle 2” revalidations are due to begin May 31, 2016. CMS notes that the next revalidation cycle has a…

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Medicare requires use of JW modifier for discarded drugs

Earlier this week, the Centers for Medicare and Medicaid (CMS), released guidance that the use of the JW modifier must be used when billing for discarded drugs for dates of service July 1, 2016 and later.  Medicare Administrative Contractors (MAC) have had latitude whether or not to require the use of this modifier, but that…

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Advance Beneficiary Notice 101 – Ophthalmic Professional

When your office performs noncovered services for Medicare beneficiaries, you need to be transparent and keep those patients informed that they may be financially responsible. Medicare’s (CMS’) formal document designed for this purpose, an Advance Beneficiary Notice of Noncoverage (ABN), is a written notice from a health-care provider to a Medicare (generally Part B for…

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When Your Medicare Cup Runneth Over – Review of Ophthalmology

The Centers for Medicare & Medicaid Services defines an overpayment as money received, usually from a third party payer, based on a claim for reimbursement that should not have been paid. An overpayment may be all or part of the payment received. It may be the result of an unintended mistake or caused by intentional…

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Revalidation of Medicare Enrollment

Several years ago, CMS put a new process in place that requires all providers with a Medicare provider number to revalidate enrollment with Medicare on a regular basis.  For physicians, nurse practitioners, physician assistants and CRNAs, it is every five years.  Suppliers, including your optical dispensary, must revalidate every three years.  The process of revalidating…

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