In an attempt to mitigate the growing backlog of appeals and the attending strain on adjudicative resources, the Centers for Medicare & Medicaid Services (CMS) are offering an administrative agreement to certain providers. CMS will pay 68 percent of the net payable value of a denied eligible claim in exchange for a hospital’s acceptance of the administrative agreement as the full and final administrative and legal resolution of the claim. CMS …Read more
On Feb. 5, 2014, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 505 and associated Change Request 8425. Transmittal 505 provided contractors with “the discretion to deny other related claims submitted before or after the claim in question.” It also allowed contractors to take action on claims that are not currently being reviewed and does not require the contractor to request additional documentation for the related claims prior …Read more
Many years ago I attended a compliance conference, and one of the speakers was a former FBI agent who did work with the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) on healthcare fraud issues. Back then there were a lot of fire-and-brimstone presentations about gun-wielding, door-breaking raids on medical practices, hospitals, and other healthcare institutions. From what I could tell, at least in …Read more
Ambulatory Payment Classifications (APCs) were launched an Aug. 1, 2000 after numerous delays. APCs represent the main payment system that comprises the OPPS, or the Outpatient Prospective Payment System. The RACs (Recovery Audit Contractors) also were launched early in the 2000s, and their activities have grown significantly over the years. Today, the Centers for Medicare & Medicaid Services (CMS) refer to...Read more
WASHINGTON, D.C. – The awarding of new Recovery Auditor (RAC) contracts likely will be delayed by at least a year following a ruling issued Tuesday by the U.S. Court of Federal Claims. The Court granted a request from CGI Federal to stay the awards of new RAC contracts in RAC regions 1, 2, and 4, the regions subject to litigation recently...Read more
On August 19, 2015, the Centers for Medicare and Medicaid Services (CMS) fired a shot across the bow of the skilled nursing facility (SNF) industry when it released MLN Matters SE1428, “Comprehensive Error Rate Testing (CERT): Skilled Nursing Facility (SNF) Certifications and Recertifications.” In this publication, CMS reported, “The SNF inpatient improper payment rate increased from 4.8 percent during the...Read more
Hospital life changed forever on Tuesday, October 1, 2013 with the Inpatient Prospective Payment that promulgated the controversial "two-midnight rule." As hospitals approach the anniversary of the two-midnight rule, what lessons can be learned? What issues surfaced this year with the implementation of the two-midnight rule in health systems with multiple electronic health records (EHR) systems in multiple settings?
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