Revenue Cycle Matters

Prescription Benefits

CMS Proposed Changes to Prescription Benefits

At the end of last month, CMS proposed a rule to change some key components of prescription coverage for Medicare Part D and Medicare Advantage beneficiaries. The key change revolves around the six protected classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for transplant rejections, antiretrovirals and antineoplastics (typically cancer treatment drugs). The six protected classes acknowledge that …

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site neutral

Medicare Advantage Denials

We have talked about managing denials in the past, but have rarely gotten payor specific. In this recent article from, they targeted in on Medicare Advantage plans. This stems from an investigation by the HHS Office of Inspector General. They have discovered a high number of overturned denials for Medicare Advantage organizations. Three-fourths between …

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site neutral

Pros and Cons of Site Neutral Payments

Last week saw a push from hospitals to lobby lawmakers about CMS’s proposal for site neutral payments. The site neutral payment proposal would be to pay the same rate for services delivered at off-campus hospital outpatient departments and independent doctor’s offices. According to CMS, they could save $610 million and patients could save $150 million …

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Insufficient Documentation CMS

The Cost of Insufficient Documentation

Insufficient documentation is the root cause for most of CMS’s improper payments. For example, according to the Medicare-Fee-For-Service 2016 Improper Payments Report, CMS paid $36.3 billion in improper payments, 64.1% of which were attributed to insufficient documentation. The guiding rule is if it didn’t happen in the documentation, then it didn’t happen at all. The …

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