Duane Abbey, PhD, CFP | April 27, 2016

Observation in the NOTICE Act: What is Being Accomplished?

The Centers for Medicare & Medicaid Services (CMS) has issued proposed regulations and a new form to address the requirements of the NOTICE (Notice of Observation Treatment and Implication for Care Eligibility) Act. This change to the SSA (Social Security Act) was enacted on Aug. 6, 2015 and is scheduled to go into effect on or about Aug. 6, 2016. CMS has included the proposed CFR (code of federal regulation) changes …

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Janelle Ali-Dinar, PhD | April 27, 2016

CMS Makes Key Move on Primary Care

The Centers for Medicare & Medicaid Services (CMS) has unveiled and launched a major expansion of its Comprehensive Primary Care (CPC) Plus model initiative for primary care physicians. It is the agency's largest-ever plan to transform and improve how primary care is delivered and reimbursed, with Medicare working with commercial payors and state Medicaid programs. The expansion of the CPC model, as released on April 11, would pay a monthly fee to …

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Frank Cohen, MPA | April 27, 2016

Text, Lies, and Statistics

According to Chapter 8, Section 4.3.2.2 of the Medicare Program Integrity Manual, “sampling units are the elements that are selected according to the design of the survey and the chosen method of statistical sampling. They may be an individual line(s) within claims, individual claims, or clusters of claims (e.g., a beneficiary). For example, possible sampling units may include specific beneficiaries seen by a physician during the time period under review; …

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04.20.2016
“Breaking Bad:” – The Frontera Complaint
“Breaking Bad:” – The Frontera Complaint

We are continuing our reporting on New Mexico's mental health situation. In June 2013, 15 providers responsible for 87 percent of the behavioral health services delivered in New Mexico were stripped of their contracts. The ostensible reason was the presence of “credible allegations of fraud.” Two years later, New Mexico's Attorney General found that there never were any credible allegations...

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04.20.2016
Are RA denials and ALJ Judgments Legal under the PPACA?
Are RA denials and ALJ Judgments Legal under the PPACA?

Value-based purchasing, bundled payments, Medicare Advantage, required quality reporting, and many Centers for Disease Control and Prevention (CDC) requirements all have one thing in common: they require reporting along an axis not defined by the Centers for Medicare & Medicaid Services (CMS) in its five criteria for a reportable secondary diagnosis.   As a reminder, those five criteria are the following: 1) Evaluation...

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04.20.2016
Resist Gaming the System
Resist Gaming the System

The time has come for me to get a little philosophical. During the April 4 edition of Monitor Mondays, we learned that the Recovery Auditors (RAs) are going to increase the number of their skilled nursing home (SNF) billing audits because previous audits demonstrated an increasing number of patients with ultra-high therapy resource utilization groups (RUGs) who just happened to...

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04.20.2016
Fingerprints Point to RAC Horror Story
Fingerprints Point to RAC Horror Story

Those who appreciate a good horror story will enjoy this article, which illustrates how very minor mistakes can spiral into abject disaster. A physician group that provides various prosthetics to patients recently had a durable medical equipment (DME) validation survey. When the surveyor sent an email with many typos, the physician group doubted the authenticity of the surveyor’s assertion that he...

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OIG

OIG Work Plan: Fair Warning

Chuck Buck | 11.04.2015

OIG Work Plan: Fair Warning

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2016 Work Plan comes with a warning: the OIG continues to be relentless in detecting and...

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Feature Articles

Physicians, Med School Grads Becoming CD…

Gracielinda Prescott | 04.27.2016

Physicians, Med School Grads Becoming CDSs as Emphasis on Clinical Accuracy Grows

Across the nation I am finding more and more medical school graduates practicing clinical documentation improvement (CDI) especially as the need for clinical accuracy grows. Some of them I have had...

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IRF

Noridian Posts Results of Recent Arizona…

Angela Phillips, PT - avatar Angela Phillips, PT | 04.06.2016

Noridian Posts Results of Recent Arizona Probe Audit:  No Surprises for IRFs

Several months ago, we discussed Noridian’s announcement of an Oregon-specific probe review for inpatient rehabilitation facilities (IRFs). Earlier this week, Noridian presented the results of that probe along with provider...

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