Chuck Buck | September 21, 2016

Hospital Alleges Third-Party Auditors Not Following Federal Guidelines

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 …

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Edward M. Roche, PhD, JD | September 21, 2016

Future of Medicare Audits, Part II: Defending Against the Tyranny of Algorithms

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 …

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Gracielinda Prescott | September 21, 2016

Federal Court Recognizes Need for Relief from Backlogged Medicare Appeals Process

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 …

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09.14.2016
What is the Square Root of -1? More Uses for Risk-Based Audit Technology
What is the Square Root of -1? More Uses for Risk-Based Audit Technology

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...

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09.14.2016
What’s in a Name? MACRA: Now is the Quality Payment Program
What’s in a Name? MACRA: Now is the Quality Payment Program

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...

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09.14.2016
Medicare Audits: DRG Downcoding in Hospitals: Algorithms Substituting for Medical Judgment Part I
Medicare Audits: DRG Downcoding in Hospitals: Algorithms Substituting for Medical Judgment  Part I

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...

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09.14.2016
Developing Story: Downgrading DRGs: A New York Epidemic Out of Control
Developing Story: Downgrading DRGs:  A New York Epidemic Out of Control

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...

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OIG

Looking Back: OIG Fraud Alert on Physici…

Gracielinda Prescott | 08.03.2016

Looking Back: OIG Fraud Alert on Physician Compensation Arrangements

This June marked a year since the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its fraud alert about physician compensation arrangements. The purpose...

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Feature Articles

What’s in a Name? MACRA: Now is the Qual…

David M. Glaser, Esq. | 09.14.2016

What’s in a Name? MACRA: Now is the Quality Payment Program

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...

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IRF

Nordian Posts Results of Recent Oregon P…

Angela Phillips, PT - avatar Angela Phillips, PT | 05.04.2016

Nordian Posts Results of Recent Oregon Probe Audit:  Once Again, No Surprises for IRFs in the Results

Last month, we discussed Noridian’s findings from the IRF Probe Audit for Arizona conducted from December 21, 2015, through March 3, 2016. At that time, we agreed to provide the...

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