NOTE: All in-article links open in a new tab.

CMS Provider Compliance Resources

Published on 

Wednesday, March 27, 2019

 | RAC Information 
 | FAQ 

Q:

I am new to Case Management and am searching for resources to help me understand more about Medicare and Medicare Policies for hospitals.


A:

Hospital Conditions of Participation (CoP)

As a new Case Manager, I would first direct you to the Conditions of Participation (CoP) for Utilization Review and Discharge Planning that can be found in the electronic Code of Federal Register: (eCFR) Title 42 Public Health

  • Part 482 (482.1 – 482.104) Conditions of Participation for Hospitals
  • §482.30 CoP: Utilization Review
  • §482.43 CoP: Discharge Planning

To help you better understand CMS’ expectations you can view their Survey Protocol in the CMS State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals.

 

CMS.gov website

There are several useful webpages available on the www.CMS.gov website. I would start with the Medicare Learning Network® (MLN) Home page.  

Medicare Learning Network® (MLN) Homepage

The Medicare Learning Network® provides free educational materials for health care professionals on CMS programs, policies, and initiatives. From the Homepage you can link to:

  • Publications &Multimedia,
  • Events & Training, and
  • News & Updates.

MLN Publications & Multimedia

One example available are MLN Articles. These articles explain national Medicare policy in an easy-to-understand format with a focus on coverage, billing, and payment rules for specified provider types. Just posted to this webpage is an index of MLN Matters® Article from 2017-2019 in pdf format. One interesting section allows you to search articles specific to individual HCPCS codes.

MLN Events & Training

In this section you will find MLN Web-Based Training page provides you free 24/7 access to web-based training (WBT) courses.

MLN News & Updates

This section provides you access to the MLN Connects weekly e-newsletter for health care professionals. CMS notes this newsletter is your single source for:

  • CMS program and policy details,
  • Updates and announcements,
  • Press Released,
  • Upcoming Educational Event Registration and Reminders,
  • Claims, Pricer, and Code Information, and
  • Updates on New and Revised MLN Publications.

Medicare Quarterly Provider Compliance Newsletter Archive

Another great resource is the Medicare Quarterly Provider Compliance Newsletter that provides education regarding how to address common billing errors and other claims review findings. You can search newsletters by common keywords, phrases, and claim review findings.

CMS National Training Program (NTP)

One additional resource to consider is the NTP website. This site provides materials and educational opportunities to help you better understand and educate others about Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.