Frank Cohen, MPA | February 18, 2015

Retrospective Baseline Probe Audits: Problems and Solutions to an Outdated Methodology

Based on surveys conducted by this author and others, it has been determined that the average large practice (greater than 150 physicians) relies upon retroactive baseline probe audits (RBPA) in order to identify patterns of compliance risk among their provider populations. In general, the methodology for a RBPA involves the services of an experienced procedural coder who is tasked with conducting a complex review of a static number of individual charts …

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Ronald Hirsch, MD, FACP, CHCQM | February 18, 2015

MACs Heading Down Slippery Slope from Medical Necessity to Quality of Care

“Don’t confuse me with the facts; my mind is already made up.” This is how William Malm, the senior manager at Craneware, describes the two recent notifications by two Medicare Administrative Contractors (MACs) who have made up their minds that they need to enter the realm of risk assessment and quality of care: a territory where they do not belong. My investigation of this was inspired by denials of outpatient ureteral …

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Amy Shaffner, RN, BSN, PHN | February 18, 2015

Looming Changes Evident in Newly Unveiled Medicare Budget

President Barack Obama’s 2016 budget report was recently released, and the news coming out of Washington, D.C. does not bode well for hospital appellants and the appeals process. The 150-page report has approximately 10 pages that are dedicated to healthcare issues. The Medicare budget includes a projected savings of $407.2 billion over 10 years and includes a $403 million mandatory multi-year investment in detecting, preventing, and prosecuting healthcare fraud. Buried in …

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02.04.2015
Everyone's a Critic – Except When it Comes to Themselves
Everyone's a Critic – Except When it Comes to Themselves

One of the objectives of the Centers for Medicare & Medicaid Services (CMS) is to move away from fee-for-service healthcare and toward pay-for-performance. But the road to pay-for-performance has not been a smooth one. The initial accountable care organization (ACO) program design was flawed, with ACOs held financially responsible for the yearly expenses of a “mystery cohort,” a group of beneficiaries...

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02.04.2015
What Does "Status" Really Mean? A Provider's Perspective
What Does "Status" Really Mean? A Provider's Perspective

Here it is January 2015, and we are still struggling with a rule put in place back in October 2013. The reasons behind the struggles vary from hospital to hospital but have a resounding theme behind most of them. If only the Centers for Medicare & Medicaid Services (CMS) could be clear in its definition of inpatient versus outpatient, we...

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02.04.2015
Some Tips for Dealing with the Early Phases of an Audit
Some Tips for Dealing with the Early Phases of an Audit

The following are a few practical tips for responding when you get a request for medical records from Medicare or a private insurer.   First, make sure that whoever is opening the mail keeps the envelope. It is relatively common for the date on a letter and the date of the postmark to be extremely disparate. In one case, a letter dated...

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CMS

CMS Releases Proposed Voluntary Face-to-…

Andrew B. Wachler, Esq. and Jessica C. Forster, Esq. | 02.18.2015

CMS Releases Proposed Voluntary Face-to-Face Templates for Certifying Physicians

  In January 2015, the Centers for Medicare & Medicaid Services (CMS) released proposed “voluntary” templates for physicians to document face-to-face encounters for home health patients. On Feb. 11, 2015, CMS...

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Feature Articles

AHA RAC Reform Proposal Sparks Concern

Chuck Buck | 02.16.2015

AHA RAC Reform Proposal Sparks Concern

With the clock ticking down on the Recovery Auditor Contractors’ (RACs’) prohibition from conducting post-payment patient status reviews with dates of admission from Oct. 1, 2013 through March 31, 2015,...

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IRF

Wishing You and Your Family Happy Holida…

Angela Phillips, PT - avatar Angela Phillips, PT | 12.22.2014

Wishing You and Your Family Happy Holidays!

To close out the year, we have provided you with a list of resources that provide the framework for inpatient rehabilitation facility (IRF) services. Each of the references has been...

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