As Medicare Advantage (MA) penetration increases arithmetically, now reported nationwide at over 30 percent of providers, the frustrations felt by hospital case management staff increases exponentially – and usually without any awareness by the people in the hospital that are responsible for negotiating those contracts. Unbeknownst to the hospital’s finance staff are the daily difficulties that often are encountered trying to get even the most basic services approved by the …Read more
The following hospitals were recently sued by a federal prosecutor: Baptist Medical Center Downtown, Baptist Medical Center South, Baptist Medical Center Beaches, Baptist Medical Center Nassau, Memorial Hospital Jacksonville, Orange Park Medical Center, Specialty Hospital Memorial Health, Lake City Medical Center, and UF Health Jacksonville. For what did they come under fire? Did they submit fraudulent bills or cause bills to be submitted to Medicare inappropriately? Nope. What is the issue? The …Read more
The Centers for Medicare & Medicaid Services (CMS) recently released new documentation detailing the number of files and records containing personal health information that have been sent through its electronic submission of medical documentation (esMD) program since 2011, when health systems were allowed to begin electronically exchanging information through health information handlers (HIH) and Medicare. As you may know, CMS defines a health information handler as “any organization that handles health …Read more
U.S. Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell recently told Congress that the agency’s plans to reduce the growing backlog at the Office of Medicare Hearings and Appeals (OMHA) include charging a refundable filing fee, hiring more administrative law judges (ALJs), and opening more field offices. While bringing more judges aboard is a much-needed step in...Read more
While the Medicaid Recovery Auditor (RAC) program has continued to struggle to return funds to the Medicare program, state Medicaid Fraud Control Units (MFCUs) continue to see significant financial returns. Released at the end of April, the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG’s) 2014 fiscal year report on MFCUs shows total recoveries of just...Read more
Hospitals have always had a difficult time distinguishing between inpatient and observation status. The two-midnight rule, originally slated to take effect on Oct. 1, 2013, provided some clarity; however, many questions remain amid repeated delays. Here is the latest update. Since the original publication of the two-midnight rule in the 2014 fiscal year Inpatient Prospective Payment System (IPPS) Final Rule,...Read more
In the April 2015 Network Bulletin, UnitedHealthcare (UHC) once again reaffirmed that it has “fully integrated the two-midnight rule into our Medicare Advantage (MA) inpatient management medical necessity review process.” While at first glance that sounds just about as straightforward as something can be, the rest of the notice and the experience of at least one hospital case manager says...Read more
Tuesday, May 12, 2015
Sixteen new Adaptive Behavior Treatment codes, which took effect January 1, 2015 are 16 reasons why your claims could be denied and your facility could be found non-compliant. The penalties are stiff, but the challenges for mastering these 16 new codes are even greater.
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