Here are few examples of your letters around claim denials due to the “experimental” nature of [certain] amniotic products.
Blog Posts by Caroline Fife, MD
Check Out Attorney Knicole Emanuel’s Post About Escalating Medicare Provider Audits to Federal District Court
Attorney Knicole Emanuel has posted a blog explaining that under some circumstances, an appeals case can be escalated to a Federal District Court.
CMS Has Quietly Reopened the Skin Substitute Evidence Door
Subscribers to CMS listservs got a very short email announcing that CMS is reopening the call for clinical evidence on skin substitutes.
The Physician Fee Schedule Proposed Rule is Out!
CMS is inviting comments on all these proposals and it is easy for you to make your voice heard during the comment period.
This Tuesday July 21 – Watch the Livestream Roundtable: Medicare Fraud: Examining the Explosive Growth in Skin Substitute Spending
The Subcommittee on Health Care and Financial Services Chairman Glenn Grothman (R-Wis.) announced a roundtable on “Medicare Fraud: Examining the Explosive Growth in Skin Substitute Spending”.
The Medicare GLP-1 Bridge: The Medicare Demonstration Program to Provide GLP-1 Medications for Obesity at $50 per Month Began July 1, 2026
Until now, Medicare has not covered drugs for weight loss. That changed on July 1.
The Skin Substitute Lawsuit, Round Two: Guest blog by Dr. Ryan Mathis
The legal fight over how Medicare pays for skin substitutes is back in court! Here’s a guest blog by Dr. Ryan Mathis to explain it.
CMS Just Released the OPPS Proposed Rule and the Skin Substitute Payment Rate Stayed the Same!
Just in time for the 4th of July holiday! CMS just released the Hospital Outpatient Prospective Payment proposed rule!
A Brief Look at the Proposed Provider Reimbursement Stability Act of 2026 (H.R. 8163)
Passage of this legislation would be best coupled with one permanently tying Medicare physician payment to the MEI.
Medicare, MIPS, Payment Cuts, Quality Measures and a Bipartisan Bill to Fix the Mess
MIPS could work, if US Wound Registry wound care relevant quality measures were available in every electronic health record (EHR).
Your Comments on Cellular Tissue Product / Skin Substitute Audits
…”now that skin sub manufacturers’ revenue has plummeted, support for clinical research (with a few notable exceptions) has plummeted.”
Medicare Auditors Are Not Wound Care Specialists: Why Providers Win Appeals When the Full Story Finally Gets Read – Blog Post by Knicole Emanuel
We will have to wait to find out if audits will lessen now that the new pricing structure has dramatically decreased the monetary incentive for audits.
Saving Lives and Limbs: What a Major New Systematic Review Means for HBOT Practitioners and Patients
A landmark systematic review has been completed which concludes that that HBOT may be one of the most important tools we have for tissue ischemia patients.
Commercial Blue Cross and Blue Shield of Texas (BCBSTX) May Downcode E/M Services Based on Automated Claims Review – Intellicure Can Help protect you
Blue Cross and Blue Shield of Texas will “enhance” its claims editing and review process for office, inpatient, and outpatient evaluation and management (E/M) services for patients in commercial plans.
Preview Your 2024 MIPS Data on the CMS Website Through Thursday, June 11
Physicians who submitted 2024 performance data in MIPS can preview that information through Thursday, June 11, at 8 pm ET on the QPP website.
An Update on the CAMPS Legal Initiative to Reverse Skin Substitute Payment Pricing – Guest Blog by Dr. Ryan Mathis
The deadline for the CAMPs Initiative to appeal the court’s decision was May 11, 2026. Here’s an update about what happened by Dr. Mathis.
UnitedHealth and CVS Health Announce Progress Toward Standardizing the Process for Prior Authorization Requests
UnitedHealth and CVS Health announced that they have standardized data and submission requirements for more than half their prior authorizations (PAs).
CMS Launches Newsletter to Help Small Practices (15 or Fewer Clinicians) Understand MIPS and the Quality Payment Program
2026 is the 6th year that practitioners could lose up to 9% of their Medicare claims under MIPS.
TMA Raises Awareness About Drug Access Limitations by Pharmacy Benefit Plans – Guest Blog by Dr. Jay Shah
Dr. Jay Shah, President of the Texas Medical Association (TMA) has provided this guest blog about what the TMA is doing to monitor the issue of pharmacy benefit plan limitations on drug access.
Trouble with Medicare “Dis” Advantage Programs? CMS has a Provider Complaint Form
The update represents a formalized mechanism for providers to raise concerns directly with CMS regarding Medicare Advantage plans.
Telehealth & Remote Monitoring Billing & Payment
CMS released an updated Medicare Learning Network (MLN) publication outlining 2026 changes.
New Medicare Advantage Complaints Process
On December 22, 2025, CMS implemented an online form on cms.gov for providers that need to report a complaint about a Medicare Advantage plan.
Off-Campus HOPDs Need a Separate NPI – Is This a Prelude to Site Neutrality? (Guest Blog by Dr. Helen Gelly)
MEDPAC has been recommending site neutrality for decades, and perhaps the powers that be at CMS are listening.
How is Medicare Prior Authorization Going for You Under WISeR in Texas? Dr. Shah of the TMA Wants to Know!
This is a rare and wonderful opportunity to have your voice heard by a powerful state medical association (with a president who is a wound care expert!)
How a Non-Pressure Ulcer Cost Measure Could Help or Hurt Your MIPS Score (and Your Medicare Payments)
CMS is going to create a wound-relevant cost measure no matter what. Let’s make sure it is as accurate and fair as possible.
Just Released! “Wound Care at Home: A Guide for Families and Caregivers”
It’s a wonderful guide for which provides instructions and explanations, and which answers the questions that patients are often afraid to ask.
Part One of My Interview on CTP Changes is Now Available on HMP Global Learning Network/Wounds
On Jan. 8, 2026, HMP posted the first part of my interview on “The Impact of CTP Changes on Provider Types.”
What We Need Next is a ZIP Code Rosetta Stone for Wound Care Outcomes
It is time to use already available ZIP code information to alert healthcare practitioners of community risk factors.
Texas Medical Association (TMA) resources for the new WISeR prior authorization program affecting CTP/skin subs
The Texas Medical Association (TMA) has a new education sheet to guide clinicians through services...
In 2026, Monetary Threshold is Higher for Medicare’s Expedited Access to Judicial Review (EAJR)
I hope those of you who are experts at the appeals process will provide some information in a guest blog about the EAJR process.
Step-by-Step Instructions on How to Download Your Field Test
CMS has posted the Cost Measure Field Test reports on the QPP website! It’s time for you to download yours!
CMS Press Release: Prepare for 2026 Field Testing of Episode-Based Cost Measures
Field Test Reports for eligible clinicians and clinician groups will be available on the Quality Payment Program Portal beginning January 29.
How to Prepare For & Make the Most of Your Field Test – Attend CMS Meetings on Jan 27 and Feb 18
CMS is holding office hours with specialty societies and organizations to provide information about the upcoming field testing period.
Here We Go Again: CMS is Testing a New “Non-Pressure Ulcer” Cost Measure
I will be posting a series of blogs explaining this in more painful detail, including a step by step guide to download your Field Test report.
Noridian Webinar Materials on Wasteful and Inappropriate Service Reduction (WISeR) Model
I attended the Noridian informational call on the Wasteful and Inappropriate Service Reduction (WISeR) model.
Breaking News! Medicare Will Not Pay for CTP / Skin Substitute Wastage “Under Any Circumstances”
Medicare fee for service (FFS) does not pay for discarded amounts of “incident to supplies” (which is how all non-BLA CTPs/skin subs are now classified) and will only pay for the amount of product furnished.
A New Era for Cellular Tissue Products / Skin Substitutes
Price controls are better for patients, Accountable Care Organizations, secondary insurers, tax payers, and the Medicare trust fund.
Breaking news! Cellular Tissue Products (CTPs) / CAMPS to be Paid at $127.28/cm2
Breaking news! Physician fee schedule finalized: CTPs/CAMPS priced at ~$127.28/cm2. Read more...
Check Out the Editorial in Med Page Today: 2 Doctors Concerned About Improper Use of Skin Substitutes
On October 8th, Med Page Today published an opinion piece about the increasing improper use of skin substitutes in chronic wounds.
Pyoderma Gangrenosum Nonprofit Kickoff Meetings “ALL THINGS PG”
There is a new, non-profit Patient and Family Advisory Council for Pyoderma Gangrenosum.
Cellular Tissue Products / Skin Substitute Applications in the Home Setting – Check Out Kathleen Schaum’s Recent Article in Advances in Skin and Wound Care
The application of a Cellular Tissue Product (CTP) / skin substitute, a surgical procedure, is out of the scope of a registered nurse.
Practitioners May Now Review Their 2024 Merit-Based Incentive Payment System (MIPS) Final Scores
To address errors with the 2024 MIPS final scores, CMS says participants have approximately 60 days to request a targeted review.
Check the OIG list of “Excluded Individuals” Before Hiring!
To avoid CMP liability, health care entities should routinely check the list to ensure that new hires and current employees are not on it.
OIG Calls for Urgent “Skin Substitute” Payment Reform Based on Analysis of Medicare Data
According to the report, in 2024, skin substitutes accounted for over 15% of the $66 billion that Medicare spent on all Part B drugs.
Dear APM Docs: Your 2023 APM Bonus Is Waiting… If CMS Can Find You
You might be participating in an APM and not even know it – that happens a lot – so there’s no harm in updating your payment information.
2024 MIPS Final Scores Won’t Publish Until Fall
Download the 2024 MIPS scoring guide for more information on performance criteria and how final scores are calculated.
CMS Warns of Fraud Scheme Around Medicare Audits
CMS has identified a fraud scheme targeting Medicare providers and suppliers. If you receive a suspicious request, don’t respond.
DEA Warning: Fraudsters Impersonating DEA Officials are Scamming Clinicians
Federal law enforcement officers are prohibited from demanding cash or gift cards from a member of the public.
Hyperbaric Physicians (and Hospital Program Managers): Check the 2023 Medicare Data! Protect Your NPI and Don’t Put Hospital Facility Fees at Risk
Check the 2023 Medicare data! Protect your NPI and don’t put hospital facility fees at risk.
Just Released: Hospital Outpatient Proposed Rule Would “Unbundle” Cellular Tissue Products (CTP) / Skin Substitutes in the HOPD
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).
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.
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.