Chuck Buck | September 28, 2016

Could DRG Downgrading be Illegal?

The possibility that diagnosis-related group (DRG) downgrading might be illegal was given added credence by a listener survey conducted this past Monday that revealed 14 percent of respondents thought the practice warranted a criminal investigation by the U.S. Office of the Attorney General. The survey was conducted during this week’s edition of Monitor Mondays, the live Internet radio broadcast produced by RACmonitor. The survey asked listeners how they would characterize the …

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Edward M. Roche, PhD, JD | September 28, 2016

Future of Medicare Audits, Part III: Artificial Intelligence and the Audit-Free Future

EDITOR’S NOTE: This is the third and final installment in an exclusive RACmonitor three-part series documenting the implementation of cyber audits by third-party auditors. In Part I of this series, we discussed the exploding number of Medicare claims and the inability of the current appeals system to handle the workload. We also reviewed how special computer algorithms are being used to downcode diagnosis-related group (DRG) claims and argued that these actions …

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Gracielinda Prescott | September 28, 2016

2017 Final Rule: Highlights for Inpatient Rehabilitation Facilities

With the publication of the final rule for inpatient rehabilitation facilities’ (IRFs’) Prospective Payment System for the 2017 fiscal year, the Centers for Medicare & Medicaid Services (CMS) continued to add quality reporting requirements to those already added by last year’s rule. The new final rule adopts the major provisions of the proposed rule and will be effective for the 2017 fiscal year, which begins Oct. 1, 2016 and runs …

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09.21.2016
Federal Court Recognizes Need for Relief from Backlogged Medicare Appeals Process
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...

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09.21.2016
Future of Medicare Audits, Part II: Defending Against the Tyranny of Algorithms
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...

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09.21.2016
CMS sees CPC+, ACOs as Future of Primary Care for Rural, Small, and Independent Practices
CMS sees CPC+, ACOs as Future of Primary Care for Rural, Small, and Independent Practices

EDITOR’S NOTE: The U.S. House of Representatives’ Energy and Commerce Committee and Ways and Means Committee recently sent a letter to U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell, urging the successful implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) so that “doctors and other healthcare providers can deliver quality care their patients deserve.” This...

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09.21.2016
Hospital Alleges Third-Party Auditors Not Following Federal Guidelines
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...

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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

Breaking News: CMS Reopens Appeals Settl…

Mark Spivey | 09.28.2016

Breaking News: CMS Reopens Appeals Settlement

Steven Greenspam, Esq. Andrew Wachler, Esq The Centers for Medicare & Medicaid Services (CMS) announced on Thursday that it would reintroduce some form of an appeals settlement plan. “CMS has decided to once...

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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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