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Compliance Risks: Not Conducting Exclusion Checks Can Be Costly

In 1977, physicians and other practitioners were mandated to be excluded from participation in Medicare and Medicaid by the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Public Law 95-142 if convicted of program-related crimes. In 1981, the Civil Monetary Penalties Law (CMPL), Public 97-35, authorized the Office of Inspector General (OIG) to impose Civil Monetary Penalties (CMPs) and exclusions against persons having submitted false of fraudulent claims to Medicare and Medicaid. In 1996-1997 the OIG’s authority also…

The Potential and Risks of Maintenance Therapy

The Jimmo Settlement Agreement in January 2013 states that qualification for Medicare coverage depends on the beneficiary’s or patient’s need for skilled care, either nursing or therapy (PT, OT, and SLP) services, and NOT on their potential for improvement. This agreement made the Centers for Medicare and Medicaid Services (CMS) update and clarify the Medicare Benefit Policy Manual (MBPM) Chapter 1 – Inpatient Rehabilitation Facility (IRF), Chapter 7 – Home Health, Chapter 8 – Coverage…

Pitfalls of the Patient-Driven Payment Model (PDPM) – Capturing Parenteral/ IV Feeding While Not a Resident

Welcome back to our blog series on PDPM! You can find the previous two blogs here:  blog #1 & blog #2. The Patient-Driven Payment Model (PDPM) is the reimbursement methodology for Medicare Part A that has been implemented for Skilled Nursing Facilities (SNFs) since October 1, 2019. The PDPM was designed to improve the accuracy of Medicare reimbursement to SNFs by basing the payment on the patient’s clinical characteristics and care needs rather than on…