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CMS investigates outlier payments.
1Proskauer Rose LLP, Washington, D.C., USA. tbrock@proskauer.com
Summary
Hospitals face increased scrutiny from the Centers for Medicare & Medicaid Services (CMS) regarding billing practices for outlier payments. Reviewing charge schedules and outlier cases ensures compliance with Medicare regulations and prepares for upcoming regulatory changes.
Area of Science:
- Healthcare Administration
- Medical Billing and Coding
- Medicare Regulations
Background:
- The Centers for Medicare & Medicaid Services (CMS) is intensifying oversight of hospital billing procedures.
- Excessive outlier payment claims have been identified among certain healthcare organizations, prompting this increased scrutiny.
Purpose of the Study:
- To advise hospitals on necessary reviews of their billing practices and charge structures.
- To ensure compliance with current Medicare regulations concerning outlier payments.
- To prepare hospitals for anticipated modifications to CMS outlier regulations.
Main Methods:
- Review of hospital charge schedules for compliance with Medicare guidelines.
- Ongoing auditing of outlier cases to verify appropriateness of charge structures.
- Assessment of medical necessity for services associated with outlier claims.
Main Results:
- Hospitals must proactively ensure their billing practices align with Medicare requirements.
- Regular internal reviews are crucial for maintaining compliance and financial integrity.
- Anticipation of forthcoming changes in CMS outlier payment regulations is necessary.
Conclusions:
- Hospitals are urged to conduct thorough reviews of their billing and charge structures.
- Proactive compliance and preparation for regulatory shifts are essential for healthcare organizations.
- Adherence to Medicare regulations and medical necessity standards will mitigate risks associated with outlier payments.