Medicare Program - Appeals of CMS or CMS Contractor Determinations When a Provider or Supplier Fails to Meet the Requirements (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) The Law Library presents the complete text of the Medicare Program - Appeals of CMS or CMS Contractor Determinations When a Provider or Supplier Fails to Meet the Requirements (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition). Updated as of May 29, 2018 This final rule implements a number of regulatory provisions that are applicable to all providers and suppliers, including durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. This final rule establishes appeals processes for all providers and suppliers whose enrollment, reenrollment or revalidation application for Medicare billing privileges is denied and whose Medicare billing privileges are revoked. It also establishes timeframes for deciding enrollment appeals by an Administrative Law Judge (ALJ) within the Department of Health and Human Services (DHHS) or the Departmental Appeals Board (DAB), or Board, within the DHHS; and processing timeframes for CMS' Medicare fee-for-service (FFS) contractors. This book contains: - The complete text of the Medicare Program - Appeals of CMS or CMS Contractor Determinations When a Provider or Supplier Fails to Meet the Requirements (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) - A table of contents with the page number of each section

In addition to reprinting the PDF of the CMS CoPs and Interpretive Guidelines, we include key Survey and Certification memos that CMS has issued to announced changes to the emergency preparedness final rule, fire and smoke door annual testing requirements, survey team composition and investigation of complaints, infection control screenings, and legionella risk reduction.

Medicare Program - Changes to the Medicare Claims Appeal Procedures (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) The Law Library presents the complete text of the Medicare Program - Changes to the Medicare Claims Appeal Procedures (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition). Updated as of May 29, 2018 Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice. This book contains: - The complete text of the Medicare Program - Changes to the Medicare Claims Appeal Procedures (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) - A table of contents with the page number of each section

Medicare Program - Limitation on Recoupment of Provider and Supplier Overpayments (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) The Law Library presents the complete text of the Medicare Program - Limitation on Recoupment of Provider and Supplier Overpayments (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition). Updated as of May 29, 2018 This final rule implements a provision of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) which prohibits recouping Medicare overpayments from a provider or supplier that seeks a reconsideration from a Qualified Independent Contractor (QIC). This provision changes how interest is to be paid to a provider or supplier whose overpayment is reversed at subsequent administrative or judicial levels of appeal. This final rule defines the overpayments to which the limitation applies, how the limitation works in concert with the appeals process, and the change in our obligation to pay interest to a provider or supplier whose appeal is successful at levels above the QIC. This book contains: - The complete text of the Medicare Program - Limitation on Recoupment of Provider and Supplier Overpayments (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) - A table of contents with the page number of each section

Medicare Program - Termination of Non-Random Prepayment Complex Medical Review (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) The Law Library presents the complete text of the Medicare Program - Termination of Non-Random Prepayment Complex Medical Review (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition). Updated as of May 29, 2018 This final rule implements requirements regarding the termination of non-random prepayment complex medical review as required under the Medicare Prescription Drug, Improvement and Modernization Act of 2003. This final rule sets forth the criteria CMS contractors will use for terminating a provider or supplier from non-random prepayment complex medical review. This book contains: - The complete text of the Medicare Program - Termination of Non-Random Prepayment Complex Medical Review (US Centers for Medicare and Medicaid Services Regulation) (CMS) (2018 Edition) - A table of contents with the page number of each section

Recoup lost time and revenue with denials management and appeals know-how. Claim denials can sink a profit margin. And given the cost of appeals, roughly $118 per claim, not all denials can be reworked. A practice submitting 50 claims a day at an average reimbursement rate of $200 per claim should bring in $10,000 in daily revenue. But if 10% of those claims are denied, and the practice can only appeal one, they lose $800 per day—upwards of $200K annually. Your medical claims are the lifeblood of operations. Don’t compromise your financial health. Learn how to preempt denials with the Denials Management & Appeals Reference Guide. This vital resource will equip you to get ahead of payers by simplifying the leading causes of denials and showing you how to address insufficient documentation, failing to establish medical necessity, coding and billing errors, coverage stipulations, and untimely filing. Rely on AAPC to walk you through the appeal process. We’ll help you establish protocols to avoid an appeals backlog and teach you how to identify and prioritize denials likely to win an appeal. What’s more, you’ll learn when a claim can be “reopened” to fix a problem. Collect the revenue your practice deserves with effective denials and appeals solutions: Know how to analyze your denials Defeat documentation and compliance issues for successful claims success Utilize payer policy for coverage clues Lock in revenue with face-to-face reimbursement guidance Refine efforts to avoid E/M claim denials Ace ICD-10 coding for optimum reimbursement Put an end to modifier confusion Stave off denials with CCI edits advice Navigate the appeals process like a pro And much more!