Today I have a few newsworthy items for you.
First, Medicare updated one of the Manuals with information on billing for patients who are in the custody of a penal authority. You can find that in the Medicare Benefit Policy Manual, Chapter 16, section 40.7. But from my review, there is really nothing new, suggesting that the Centers for Medicare & Medicaid Services (CMS) is simply putting into the Manual what has been established policy.
As a reminder, payment for care rendered to patients who are considered “in custody” is the responsibility of the incarcerating agency. And this actually falls into a broader category of Medicare payment exclusions that is outlined in 42 CFR § 411.4, which prohibits Medicare payment when neither the individual beneficiary nor any other person or organization (by reason of such individual’s membership in a prepayment plan/insurance or otherwise) has a legal obligation to pay for the item or service.
That means that unless the jail or prison charges all patients for medical care, Medicare will not pay for care provided to those patients who have Medicare coverage.
But most importantly, this is a chance for me to remind you that the term “in custody” in this regulation also refers to escaped prisoners. So if an escaped prisoner presents to your hospital for care and is a Medicare beneficiary, you are obligated to find out from where they escaped and bill that entity for the medical care (and not Medicare).
Moving on, as some of you know, I am allergic to clinical documentation integrity (CDI); just talking about it gives me hives. But I have once again premedicated to be able to share a brief update. The diagnosis of malnutrition is one that payers love to remove from claims in order to pay the hospital less.
And two weeks ago, the New England Journal of Medicine published a review article on malnutrition in older adults. This article referred to Global Leadership Initiative on Malnutrition (GLIM) criteria without a mention of American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. This means that payers will latch onto this authoritative journal and demand patients meet those criteria to validate the diagnosis.
You can certainly fight for the right to use ASPEN, but CDI teams should be certain to review the GLIM criteria and anticipate the possibility of increased denials.
Finally, it appears that the U.S. Department of Veterans Affairs (VA) inappropriately paid some claims under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) for patients who had other insurance as far back as 2021, and they are going to demand refunds. But after you refund the payment, via an online portal, they say you can bill the primary insurance, and if that claim is rejected, you can then resubmit the claim for payment.
Now, I would love to know if they really think any insurer is going to pay a claim that is submitted more than one year after the date of service. We all know every such claim will be rejected, and then the provider must go through the resubmission process, only to get the payment they just refunded. Talk about government inefficiency; how hard would it be to put an edit only asking for repayment for claims within the last year?
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
That’s how Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz announced the publication of the CMS Final Rule on the Adoption of Standards
As we enter the first year of post-Loper Bright v. Raimando, the landmark U.S. Supreme Court decision overturning so-called Chevron deference, healthcare providers should push
Please log in to your account to comment on this article.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Stacey Shillito, CDIP, CPMA, CCS, CCS‑P, CPEDC, COPC. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s third quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
BLOOM INTO SAVINGS! Get 25% OFF during our spring sale through March 27. Use code SPRING26 at checkout to claim this offer.
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
