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The Comprehensive Care for Joint Replacement Model that begins April 1, 2016 is a CMS demonstration that proposes to adopt prior authorization processes and bundle home health reimbursement with the acute care hospitalization costs.
CMS is not complying with the class-action Jimmo v. Sebelius settlement of 2013 requiring CMS to stop Medicare providers from denying medically necessary maintenance nursing and therapy to beneficiaries, including those who qualify for home health services.
The Center for Medicare Advocacy announced March 1, 2016 that the plaintiffs' attorneys, the Center for Medicare Advocacy, and Vermont Legal Aid filed a Motion for Resolution of Non-compliance with the Settlement Agreement asking Vermont Chief Judge Christina Reiss to enforce CMS' promise to end the illegal practice.
During a spot-check quality audit, you discover that the documentation in the patient record doesn't support the amount Medicare paid for the claim. Alarmed, you search the record for any misfiled documents and ask those involved with the patient's care if key information was documented correctly. After your frantic search it is clear that Medicare overpaid your agency for the services in a payment episode several months ago.
Yikes! You know the agency must repay Medicare. But isn't it too late? Was accepting the overpayment in the first place fraudulent?
Got questions about ICD-10 diagnosis coding for hospice or home health?
Until recently, diagnosis coders had no option but to request official diagnosis coding guidance and clarification from CMS' designated coding gurus at the American Hospital Association's (AHA) "Coding Clinic." But hospice and home health agencies report receiving conflicting and/or inapplicable guidance that could lead to payment delays or claim denials.