Monthly Newsletter

December 2021 Monthly Newsletter

Career Center

Is an executive or employee on your workforce an AIHC Member? If so, your organization can post open compliance, coding & management positions FREE!  Not a member? Pay only $25 per posting or Join for unlimited job posting ability!  Our job postings are listed on our website and boosted through our email news blasts, which reach thousands of our members, subscribers, and affiliates. Click Here to Post a Job. View the Interview Tutorial Videos and Job Listings.

NCQA Launches Program to Highlight High Performers in Antibiotic Stewardship

Antibiotic resistance affects 2.8 million people annually as a result of overprescribing antibiotics. An estimated 30% of outpatient antibiotic prescriptions are unnecessarily prescribes, according to research published by the Pew Charitable Trusts (Pew) and Centers for Disease Control and Prevention (CDC).

The National Committee for Quality Assurance (NCQA) has launched an antibiotic stewardship program as a means to improve how antibiotics are prescribed by clinicians and used by patients.

The development, implementation and use of quality measures can bolster stewardship efforts. HEDIS®, our set of health plan performance measures, includes three antibiotic prescribing measures for bronchitis/bronchiolitis, upper respiratory infection and pharyngitis — three conditions that drive significant levels of inappropriate prescribing in the U.S. The high performers program aligns with the goals of Pew’s antibiotic resistance project, which seeks to advance antibiotic stewardship efforts across healthcare settings in order to combat the growing threat of antibiotic resistance. Click Here to learn more from NCQA.  Click Here for the PEW Antibiotic Resistance Project webpage.

FTC and Competition in the Health Care Marketplace

The Federal Trade Commission (FTC) and its staff advise federal and state governmental bodies on competition issues in health care in an effort to provide policymakers with a sound basis for assessing the implications for competition and consumers of proposed legislative or regulatory actions.  Click Here to access the FTC webpage.  Scroll down and click to review cases, press releases, and we recommend choosing videos to learn more about your rights as a health care provider.

Get the Short List of 2022 CMS Policies

The Centers for Medicare & Medicaid Services (CMS) created a 7-page Fact Sheet MM12519 to summarize policies related to:

  • Updates to payment policies and Medicare payment rates for services physicians and Non-Physician Practitioners (NPPs) provide that Medicare pays for with the MPFS in CY 2022
  • Updates to Medicare Telehealth Services and Telehealth origination site facility fee payment amounts
  • Billing for Physician Assistant (PA) Services and other policy changes related to Medicare Part B

Make sure your billing staff knows about these changes.  Information is effective January 1, 2022 with an implementation date of January 3rd 2022. 

Get the Telehealth Final CY 2022 PFS Fact Sheet – published by the National Telehealth Policy Resource Center. This is a comprehensive overview of the Consolidated Appropriations Act, FQHCs/RHCs and new definition of mental health and telehealth, CTBS, OTPs and on the last page, a CY 2022 Medicare Reimbursement for Mental Health Services via Telehealth & Audio-Only flowsheet.

Medical Necessity Updates

ICD-10-CM NCDs: Effective April 1, 2022

If your organization files claims to a Medicare Administrative Contractor (MAC) for services provided to Medicare patients, it isn’t too early to review April 2022 revisions to National Coverage Determination or NCDs.  This early review of upcoming changes provides sufficient time to determine if any adjustments are required related to applicable services and Medicare coverage issue.

To learn about ICD-10 conversion and other coding updates specific to NCDs in two updates.  Click Here for Update 1 and Click Here for Update 2.  These changes result from newly-available codes, separate NCD coding revisions and coding feedback.

Provide Compliance Tips – Interactive Chart to Learn Medical Necessity Coverage from CMS

If your organization’s providers order and bill Medicare for items and services, it is vital for both clinical and billing workforce members to gain a better understanding of medical necessity, coverage and compliance.  When an item may be denied due to lack of meeting medical necessity, it is important to follow guidelines related to the Advanced Beneficiary Notice policies.


Click Here for the MLN Education Tool Medicare Provider Compliance Tips!

Click Here for the AIHC free educational video on ABNs, Medical Necessity and Medicare Rules. Check out all our free educational videos.

Compliance Enforcements

$5.5 Million Dollar Settlement by Hospice Due to Whistleblower

Crossroads Hospice of Ohio and Tennessee pay a $5.5 million settlement for submitting false claims to Medicare for hospice services for patients who were not terminally ill.

Patients admitted to hospice are considered to be terminally ill and hospice-eligible when they have a life expectancy of six months or less if their illness runs its normal course.  According to the settlement agreement, the United States alleged that Crossroads Hospice billed Medicare for hospice care for certain patients with a diagnosis of dementia or Alzheimer’s disease at its Ohio and Tennessee locations who were not terminally ill for at least a portion of the more than three years that the patients received care at these locations.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Leanne Malone, Jackie Burns and Angela Heck, former employees of Crossroads Hospice, as well as Dr. David Weber, a home health physician in Tennessee.  Read more about this case.  Learn more about the False Claims act (FCA) and compliance today – enroll in the online Corporate Compliance training program w/option to certify included in course tuition.

OIG Report: Medicare Improperly Paid DMEPOS Suppliers $117 Million Provided to Hospice Beneficiaries

The Office of Inspector General (OIG) audit covered $185.7 million in Medicare Part B payments to suppliers for 1.6 million DMEPOS items provided to hospice beneficiaries for the audit period of January 2015 through April 2019.

The OIG found that 58 percent of the sampled DMEPOS items billed without the GW modifier (67 of 115 items) and 63 percent of the sampled DMEPOS items billed by suppliers with the GW modifier (54 of 85 items), the items were provided to palliate or manage the beneficiaries’ terminal illnesses and related conditions. Medicare pays the hospices for the DMEPOS items provided to the beneficiaries as part of the hospices’ per diem payments. These items should have been provided directly by the hospices or under arrangements between the hospices and the suppliers. The improper payments occurred because these issues were revealed during the OIG audit that the:


  • Majority of the suppliers were unaware that they had provided DMEPOS items to hospice beneficiaries;
  • System edit processes to prevent improper payments were not effective or did not exist; and
  • Suppliers inappropriately used the GW modifier.

The OIG estimates that Medicare could have saved $116.9 million in payments during the audit period, and beneficiaries could have saved $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf. Read the Report Brief or Download the Complete Report.

Bribery, Kickbacks, Genetic Testing and Conspiracy

Terri Haines made a living soliciting and collecting DNA samples from Medicare patients at health fairs. Haines is the fifth defendant to plead guilty in bribery and kickback schemes involving doctors and medical employees in the Scranton, Pennsylvania, area.

Haines then sent the DNA samples to a lab in New Jersey for “CGx” cancer screen testing in exchange for commission. Haines was not authorized to order those CGx tests without a doctor’s sign-off. As a result, Haines paid a kickback and bribe to Dr. Lee Besen, of Scranton, Pennsylvania, to use his name and medical credentials to order CGx tests for the Medicare patients she met at fairs, even though Besen never actually attended any of the health fairs and never met the patients for whom the genetic tests were ordered.

The count of conspiracy to violate the federal anti-kickback statute is punishable by a maximum of five years in prison and a fine of $250,000, or twice the gross gain or loss derived from the offense, whichever is greatest. Sentencing is scheduled for March 22, 2022. Read more about this case.


Online Training 

with the option to certify online


Online Training

with the option to certify online


Online Training

with the option to certify online


Online Training

with the option to certify online


Online Training

with the option to certify online

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