I will try to post a better analysis of the impact of these proposals in the HOPD (hopefully provided by readers who understand this better than I do).
Blog Posts by Caroline Fife, MD
Show Me the Regulation!
When clinicians or management companies ask why a process must be done in a certain way, they are told, “It’s a regulatory requirement.”
BREAKING: 2026 MPFS Proposed Rule sets single payment for all CTPs at $125.38/cm2
There will no doubt be a significant response from manufacturers and clinicians in response to this proposal.
Scam Alert! CMS Issues Warning on Medicare Audit Phishing Scheme
Increased awareness of the Medicare audit climate could cause clinicians to be fooled by these scams. Watch out!
RFK Jr. and Dr. Oz Pledge to Fix Broken Prior Authorization System
heir commitments reinforce the role of CMS in monitoring outcomes and promoting accountability.
BREAKING NEWS in the DOJ Press Conference! More Skin Substitute / Cellular Tissue Product (CTP) Fraud Indictments
Wound Care, specifically around the use of amniotic “skin substitutes,” made the news in the fraud press release.
Site Neutrality – a Looming Disaster or an Opportunity?
Now may be the time for academic programs and large hospital systems that still provide needed emergency hyperbaric services to start contacting their congressmen.
The Quality Payment Program (QPP) “Doctors and Clinicians Preview Period” for 2023 is Officially Open
Clinicians who reported data as part of the Quality Payment Program (QPP) in 2023 can preview their 2023 performance information before it appears on the Medicare.gov compare tool and in the Provider Data Catalog (PDC).
DOJ Unveils a New Corporate Enforcement & Voluntary Self-Disclosure Policy (CEP)
The Department of Justice’s Criminal Division is “turning a new page on white-collar and corporate enforcement.”
Providers Under Siege
The stakes go beyond money: reputational harm, exclusion from Medicare and Medicaid, and even criminal charges are on the table.
States Try to Limit the Use of AI in Prior Authorization
Read the complete article for more details on what individual states are doing to push back on the use of AI in Prior Authorization.
CTP-related LCDs Postponed at the Last Minute!
The LCDs that will directly impact CTPs (Skin Subs) have been postponed until January 1, 2026! Announcement came at the last minute!
Overzealous Medicare Audits
Be sure to read all of Ms. Emanuel’s article, which calls for radical reforms such as holding auditors accountable for mistakes.
Hospitals & Doctors Spend a Lot of Money Just Trying to Get Paid
No wonder practitioners in private practice have been tempted by the big dollars to be made from skin substitutes.
What Happened to “Innocent Until Proven Guilty? Check Out this Article on Medicare Recoupment
Check out Knicole Emanuel’s recent blog post about CMS monetary recoupment before full adjudication.
Fewer Regulatory Hoops but Continued Scrutiny on Fraud Under the Trump Administration
While the Trump Administration may be reducing the regulatory burden in many areas of government, they are NOT reducing their focus on reducing on fraud investigations.
The Cigna Group Launches Actions to “Drive Positive Change for Customers & Patients”
There are five key areas of focus, and several initial specific actions, to improve the health of its customers and the value it provides.
ACA Healthcare Plan “Just Say No” to 1 in 5 Claims
ACA insurers denied 1 in 5 medical claims in 2023, the highest rate since 2015.
Murphy Introduces Bipartisan Legislation to Preserve Medicare for Patients and Physicians
I worry that the misbehavior of a small percentage of practitioners will reduce enthusiasm for a bill to fix a huge physician reimbursement problem.
A Titanic Shift at CMS: The Push to Trim Administrative Costs & Increase Audits – Knicole Emanuel’s Recent Post
Ms. Emanuel likens CMS to the Titanic in terms of how hard it will be to turn such a massive ship. Let’s hope this story will end differently.
“Defending Against Medicare and Medicaid Audits: A Guide for Healthcare Providers” by Knicole Emanuel
She notes that, “Recent statistics show that CMS, through its contractors, conducted over 300,000 audits in recent years.”
Noridian Surgical Dressings Webinar – 02/11/2025
The Noridian Provider Outreach and Education staff is hosting the Surgical Dressings webinar on 02/11/2025, 12:00 PM – 1:30 PM EST.
Landmark Antitrust Settlement Calls for Blue Cross Blue Shield to Pay $2.8 Billion into a Fund Designated for Physicians and Others
The fund is designated for settlement class members, including physicians, group practices, and health care facilities.
LCDs Delayed Until April 13, 2025
If you scroll to the end of the LCD, it will state the future effective date of 4/13/25.
American Relief Act Extends Some Telehealth Waivers Including Audio-Only Telehealth
The continuation of Medicare telehealth flexibilities follows another recent telemedicine extension by the DEA and the Department of HHS.
BREAKING NEWS: Wound Care Company Owners Plead Guilty to $1.2 B in Fraudulent Claims for Amniotic Products and Face Prison
The case was handled through the Health Care Fraud Strike Force Program, which currently operates in nine Strike Forces across the country.
Physicians Have Concerns Over the Implementation of Medicare’s Add-on Code for Complex Care (G2211)
The rules are complex, and a billing and coding expert may need to provide guidance to wound care practitioners.
Changes to the Administrative False Claims Act (AFCA) Mean That “Smaller” Medicare Fraud Cases (Up to $1 Million) Can Be More Easily Prosecuted
This legislation also makes it more likely that individuals who act as “whistleblowers” could realize the associated monetary rewards.
The New LCDs are (Almost Certainly) Coming to Town
I may post more information about the meeting later, but the general tone of the MAC medical directors was confident.
CGS Chief Medical Officer is Hosting a Meeting on the New Cellular Tissue Product / Skin Substitute LCD on December 20th
CGS J15 Webinar on Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
AMA sues MultiPlan Alleging Price-Fixing for Out-of-Network Physician Payments
The American Medical Association (AMA) and the Illinois State Medical Society (ISMS) have filed a lawsuit in federal court.
CMS Releases the Medicare Physician Fee Schedule Final Rule for 2025
The sad news is that CMS is going ahead with a 2.9% cut to Medicare physician reimbursements for 2025.
CMS Releases 2025 Final Rule for the Hospital Outpatient Prospective Payment System (OPPS)
The short version, based on my cursory read, is that no old problems were fixed but no new problems were created by the final rule.
Breaking News! LCDs for Cellular Tissue Products / Skin Substitutes Released!
LCD – Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (L39756)
Bipartisan Bill Introduced That Would Provide a 4.7% Medicare Physician Payment Update
It would eliminate the 2.8% Medicare physician payment cut and provide a positive update that equals half of the Medicare Economic Index.
FDA Approves Changing the Expiration Date of Some IV Fluids Made by Baxter to Help Alleviate Shortages
Baxter International is one of the largest suppliers of IV fluids in the United States with its North Cove facility providing 60% of IV fluid in the USA.
Check Your Final 2023 MIPS Scores Available Online – Scores Will Impact 2025 Physician Payment!
Should an error be found, the deadline to request a review is Oct. 11 at 7 pm CT.
“To Self-Disclose or Not to Self-Disclose”: Check Out Attorney Knicole Emanuel’s Blog
Self-disclosure is better than waiting to get caught. Lives can be ruined if you wait to get caught.
Templated Notes and Medicare Audits
If practitioners encounter denials by auditors based on the use of note templates, they should probably seek legal counsel.
Loss of Baxter Facility in N.C. from Helene is Affecting Availability of IV Solution and Shortages May Worsen Due to Hurricane Milton
Hospitals are facing shortages of IV fluids following Hurricane Helene’s damage to Baxter International’s North Cove manufacturing site in Marion, N.C.
Reminder: Final Scores for the 2023 Performance Year of Medicare’s Merit-Based Incentive Payment System (MIPS) are Now Available Online and the Deadline to Request a Review is October 11 at 8 PM ET
Check your scores soon as they will impact your 2025 Medicare payment!
UnitedHealthcare Launches a “Gold Card” Program in October to (Hopefully) Reduce Prior Authorization Woes
The program will be offered across its commercial, individual exchange, Medicare Advantage and Medicaid business lines.
Due to the Impact of Beryl, CMS Has Automatically Applied a Hardship Exemption Within the 2024 Merit-Based Incentive Payment System (MIPS) Performance Period to Eligible cC Areas
The extreme and uncontrollable circumstances (EUC) policy will apply in affected Texas counties as identified by federal public health emergency and disaster declarations.
Check Out the New Article in TWC “I’m Getting Audited – Now What?” by Stephen Bittinger
Mr. Bittinger’s article explains the various types of audits, what’s at stake, and how an attorney might help.
Aetna to Cut Payment for Urgent Care Surgical Services and Payments for NPs and PAs
Wound Care practitioners who bill site of service 49 (independent clinic) take note!
The Average Cyberattack Breach Costs ~$11 Million – and the Number of Attacks Per Week is Increasing
Ransomware attacks have dominated, accounting for over 70% of successful cyberattacks on healthcare organizations in the past two years.
In 2025, Physicians Face a 2.8% Pay Cut While Mandatory Participation in an MVP Looms
In 2024, physicians had a 1.68% pay cut and they remain the only Medicare providers to not receive an inflationary update.
Does Which EHR a Doctor Uses Impact the “Cost” Category of MIPS?
Wound care practitioners have higher TPCC costs when compared to their peers. To CMS, they look like they spend too much money.
Noridian and CGS Release FAQs on Lymphedema Compression Treatment Items
Noridian and CGS Provider Outreach and Education have released the most frequently asked questions (FAQs) on lymphedema compression treatment items under the Lymphedema Treatment Act.
Health Information Technology Proposed Rule (HTI-2) is Out
ONC will be hosting information sessions in the coming weeks, including an overview session on July 17 at 2:00 PM ET.
Global Internet Outage Continues to Impact Many Healthcare Systems
Human error may be just as much of a risk as hacking, ransomware and other intentionally malicious assaults.
2025 Medicare Physician Fee Schedule is Out (and CMS Did Not “Package Price” Cellular Tissue Products / Skin Substitutes in the Doctor’s Office)
The billing of CTPs in the doctor’s office is unchanged. The 2025 Medicare conversion factor is set to decrease for the fifth straight year.
Breaking News! OPPS Proposed Rule is Out!
At first glance, there are no changes to Cellular Tissue Product /skin substitute payment, which remain under package pricing in this site of care.
Accelerated and Advance Payment (AAP) for Medicare Ends on July 12
CMS announced that Medicare payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will end on July 12.
CMS Adds 76 New Items to its Master List of DME Supplies That May Be Subject to Prior Authorization (and Some Surgical Dressings are on the List)
The Centers for Medicare & Medicaid Services (CMS) added 76 new items and deleted three from its master list of durable medical equipment (DME), prosthetics, orthotics, and supplies.
How the DEA is Working to Help Communities Get Rid of Unused or Expired Prescription Medications
You can find a medication collection site by putting in your zip code on the Collection Site Locator.
How to Subscribe to the NGS Self Service Plus Newsletter
If NGS is your MAC, you might want to subscribe to the Self-Service Plus newsletter, accessed online.
Physicians Have Until Dec. 31 to File a MIPS Hardship Exemption Due to the Change Cyberattack
The 2024 MIPS EUC portal is now open, and physicians have until Dec. 31 to file a hardship application and avoid a 2026 MIPS negative payment adjustment.
What Doctors Wish Patients Knew About Prior Authorization
Maybe if I’d let patients read this article, I could have discussed the issue with my patients honestly, rather than just running away from it.
Pneumatic Compression Devices Are in the Spotlight for 2024 Audits
Check out the article by Knicole Emanuel in Today’s Wound Clinic: Pneumatic Compression Devices Are in the Spotlight for 2024 Audits.
CMS Explains its 2024 Value-Based Care Strategy
CMS ALWAYS tell us what they are going to do before they do it. Then they do it, and we are surprised.
A Little Reprieve for Physician Pay Cuts
A 3.4% Medicare physician pay cut took effect on January 1, 2024. However, thanks to the passage...
CMS Announces Flexibilities in the Wake of the Change Cyberattack
CMS is encouraging MA plans to offer advance funding to health care professionals most affected by the cyberattack.
CMS Announces Reopening of 2023 MIPS EUC Application in Response to Change Healthcare Cyberattack
I am reposting the entire message from the CMS about the extension of the Extreme and Unavoidable...
CMS Removes the Requirement for AUC From the 2024 Medicare Physician Fee Schedule
Implementing the AUC program would have been a time consuming and expensive lift for practitioners.
Update on the Surgical Dressing Policy – Thanks to the Alliance of Wound Care Stakeholders
The Alliance of Wound Care Stakeholders has had another policy win!
Resources from CMS and the AMA to Help You Implement Changes to Physician Documentation & Billing
There have been two major changes in the regulations pertaining to physician documentation during ambulatory visits, both of which are favorable for wound care practitioners.
Medicare Audits on Pneumatic Compression & Surgical Dressings – “It’s About the Documentation…”
I am a huge fan of attorney Knicole Emanuel’s blog and her most recent post is directly relevant to the field of wound care.
Be Careful Billing the New CMS G2211 Add-on Code for Visit Complexity
It is intended to “better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”
Claims Disruptions Continue After Cyberattack on Change Healthcare
This is yet another blow to hospitals and physicians that are struggling to make ends meet in the face of payment reductions.
Ransomeware Cyberattack on Change Healthcare is Affecting Individual Physician Practices Too
United Health-owned Change Healthcare has confirmed the ransomware group “ALPHV/Blackcat” is...
CMS Final Rule on Prior Authorization Released
Prior authorization (PA) is costly, inefficient and responsible for patient care delays. The...
Surgical Dressing Webinar by Noridian on March 7th
On Thursday, Mar 7, 2024 from 12:00 PM – 1:00 PM CST, Noridian is offering a webinar on Surgical Dressings. It is intended for DME suppliers.
Noridian Offering Tutorials on Hyperbaric Oxygen Therapy (HBOT)
Noridian is offering two self-paced training tutorials to “assist providers and facilities in better understanding Hyperbaric Oxygen (HBO) Therapy.”
Novitas Releases Top Ten Reasons for Claims Denials…and Wound Centers Should Especially Check Out Reason #7
Reason #7 for claim denials is especially relevant to hospital-based outpatient wound centers (HOPDs).
Noridian is Offering a Feb 13th Webinar on the Lymphedema Compression Benefit Category
On February 13th, 2024, Noridian is offering a Webinar for DME suppliers about lymphedema compression benefits.
Pneumatic Compression Devices Webinar by Noridian on Feb 13th, 2024
On Tuesday, Feb 13, 2024 from 2:00 PM – 3:00 PM CST, Noridian is offering a webinar intended for DME suppliers about pneumatic compression devices (PCDs).
The Deadline to Submit MIPS Data for 2023 is April 1 at 6 pm EST to Avoid up to a 9% Penalty on Medicare Revenue
The data submission period for Medicare’s Merit-Based Incentive Payment System (MIPS) 2023 performance year is underway.
Time Sensitive! It’s Not Too Late to Sign the Letter to CMS Protesting the 41.5% Reduction of HBOT Facility Fees!
I know the holidays are busy – but most of us would like to have a job to go back to in January…
Without Warning – the Outpatient Prospective Payment Final Rule Cuts HBOT Facility Fees by 40%
What we need is for people to submit a comment, and to spread the word that hyperbaric oxygen therapy is in a crisis.
Modifications Needed to Wound Center EHR to Support DME Orders for Dressings
Your EHR will need to be modified to meet the DME documentation requirement burden (and if you think the list below is ridiculous – it is, but it’s still required).
Mindfulness, Electronic Health Records and Ebola
A recent Ebola outbreak in Dallas was blamed on a “flaw” in the hospital’s electronic health record (EHR). Yes, you heard me correctly.
Observations About the 2024 PFS Pertaining to Cellular and/or Tissue-Based Products in the Doctor’s Office Setting
On July 13, 2023, CMS issued proposed rules for the 2024 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS).
“Hidden RAC Audits” – Seriously…
Attorney Knicole Emanuel has posted a chilling blog on her site about hidden RAC (Recovery Audit Contractor) audits.
Listen to a Podcast with Dr. Helen Gelly, “How to Get Your Wound Clinic Through an Audit”
On your drive home, check out this podcast with Helen Gelly MD, FUHM, FACCWS, UHM/ABPM, “How to Get Your Wound Clinic Through an Audit.”
HBOT Facility Payments are Under Attack (Physician Supervision is Next…)
We need individuals at all training levels to comment on the proposed changes that CMS is proposing in the Medicare Physician Fee Schedule (MPFS) for the technical payment of HBOT.
Check Out the Long List of CTPs (“Skin Subs”) Not Covered in the CGS, First Coast, & Novitas LCDs
Three Medicare Administrative Contractors (MACs) issued their final Local Coverage Determinations (LCDs) for Cellular and/or tissue-based products (CTPs).
Highlights of the 2024 Outpatient Prospective Payment System (OPPS)
You should read the documents yourself, but here are some highlights of the 2024 OPPS proposed rule (in no particular order).
PRESS RELEASE: New Study in Journal of Medical Economics Shows Decrease in Chronic Wound Medicare Costs Amid Increase in Chronic Wound Prevalence
Over 2014-2019, the number of Medicare beneficiaries with chronic wounds increased 13% to 10.5 million amid a surprising 20% reduction in chronic wound expenditures. Researchers seek to explain why, and what the policy implications may be.
Chiropractors Treating Diabetic Foot Ulcers?
I am highly suspicious that this is being driven by the manufacturers of CTPs, and is yet another indication that the CTP industry is out of control.
Prior Authorization Nightmares & the Antidote to Burnout
Here’s a doctor who knows his days are numbered, and he’s making the most of every one because he has a purpose.
HIPAA Does NOT Require That Healthcare Providers Obtain Patient Authorization to Disclose Protected Health Information (PHI) to Other Clinicians for Treatment Purposes
HIPAA does NOT require that health care providers obtain patient authorization to disclose protected health information (PHI) to other clinicians for treatment purposes.
Medicare Extrapolation Under 50% Error Rate? No Extrapolation ALLOWED!
In Knicole Emanuel’s latest blog, she discusses the new Medicare rules stating that no extrapolation may be run if the error rate is under 50%.
The Quality Payment Program and What it Means for the Future of Wound Management & HBOT
The Big Picture of Physician Payment Within CMS The big picture is still playing out for physician...
The Lymphedema Treatment Act Passed!
The LTA will improve insurance coverage for the medically necessary, doctor-prescribed compression supplies that are the cornerstone of lymphedema treatment.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans – Review of Medical Necessity Requirements
Undersea and Hyperbaric Medicine IS a recognized medical subspecialty so that might help patients obtain necessary HBOT treatments.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans
The rule goes into effect Jan 1, 2024. Whether this will make MA less of a Medicare DIS-advantage is yet to be seen.
CMS Published 2023 Medicare/caid Health Care Providers’ Audit Process – Read Attorney Knicole Emanuel’s Offer to Clinicians Being Audited
Nearly every wound care and hyperbaric medicine practitioner is undergoing some sort of Medicare audit.
Wound Care Services and the Jimmo Settlement – Why it Matters to Patients Who Are in Palliative Wound Care
Unfortunately, some Medicare auditors are not following the law as it pertains to the presence or absence of a beneficiary’s potential for improvement.
Are Verbal Orders Prohibited?
There are no federal regulatory prohibitions on the use of verbal orders, although CMS frowns upon verbal orders in the context of medications.
Caroline Fife, MD
Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.