James Jones, MD The irony is stupefying. One of America’s oldest teaching hospitals is spending in excess of $1 million annually to defend itself from third-party auditing vendors that refuse to follow federal coding guidelines. That is what is happening currently at Mount Sinai Health System in New York City, where the embattled organization receives approximately 200 to 250 audits monthly from healthcare payers. Unfortunately, the win rate for the venerable teaching …Read more
EDITOR’S NOTE: This is the second in an exclusive RACmonitor three-part series documenting the implementation of cyber audits by third-party auditors In Part I of this series, we reviewed how the number of Medicare audits has increased by almost 1,000 percent in the past five years, and how virtually no decisions by administrative law judges (ALJs) are being issued within the statutory time frame. We also discussed how Recovery Auditors (RAs) have started …Read more
A federal District Court in the District of Columbia on Monday denied the U.S. Secretary of Health and Human Service’s request for a stay of proceedings in a federal action brought by the American Hospital Association (AHA) and other providers seeking judicial relief compelling the Secretary to process Medicare appeals in compliance with statutorily designated time frames. The Secretary requested a temporary stay in the legal proceedings to allow the Department …Read more
I recently received an email from a Monitor Mondays listener about something called TPEE, or targeted probe and educate with extrapolation. I did a little research and came across a pretty neat flowchart that described the program as a multi-phased approach to improving coding and billing compliance through provider education. While my suspicions are always aroused when a payer claims to...Read more
Last week the Centers for Medicare & Medicaid Services (CMS) indicated that when the final rule is issued for the Merit based Incentive Payment System (MIPS), it will be different than the proposed rule issued this Spring. I know most of you know that MIPS, is part of Medicare Access and CHIP Reauthorization Act (MACRA). But when your acronym has...Read more
EDITOR’S NOTE: This is the first in an exclusive RACmonitor three-part series documenting the implementation of cyber audits by third-party auditors. The number of Medicare audits is increasing. In the last five years, audits have grown by 936 percent. As reported previously in RACmonitor, this increase is overwhelming the appeals system. Less than 3 percent of appeal decisions are being rendered...Read more
Sonya Manuel Do you find that your facility’s DRGs are being downgraded by third-party payers that are re-diagnosing patients? Are they also discounting the coding of suspected and possible diagnoses? You’re probably not alone. Sonya Manuel, a senior health information management (HIM) consultant and DRG coordinator for Jzanus Consulting in New York, tells RACmonitor that the battle with third-party auditors has been...Read more
By attending this timely webcast, you will be made aware of the potential impact that the JW modifier can have on your organization and also know how critical documentation and medical necessity are to a successful transition.
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