Jessica Forster, Esq. and Kevin R. Miserez, Esq. | August 19, 2015

Court’s Interpretation of “Identified” Overpayments Imposes a “Demanding Standard of Complia

  On Aug. 3, in the case of Kane v. Healthfirst, Inc., et. al., the Southern District of New York issued the first court opinion interpreting the 60-day overpayment provision of the Patient Protection and Affordable Care Act (PPACA). When a person has received a Medicare or Medicaid overpayment, the PPACA requires the person to report and return the overpayment within 60 days from the date the overpayment was “identified.” Failure …

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Steven J. Meyerson, MD | August 19, 2015

A One-Midnight Rule Solves Many Problems

EDITOR’S NOTE: The public comment period on the proposed two-midnight rule ends on Aug. 31, 2015. Send your comments to the Centers for Medicare & Medicaid Services. See details in this article. The two-midnight rule was supposed to clarify Medicare criteria for admission, but it left many issues unresolved. I would like to explain my proposal for a simplified one-midnight admission rule that would replace the two-midnight rule. Here’s how a one-midnight …

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Nicole Smith | August 19, 2015

State of the Recovery Audit Contractor Program

The Recovery Auditor (RAC) program may see significant changes in the near future, as the Centers for Medicare & Medicaid Services (CMS) has issued the proposed 2016 Inpatient Prospective Payment System (IPPS) rule.  Among other things, the new guidelines address the controversial two-midnight rule, which has resulted in the pause of inpatient status reviews for the RAC program since 2014. Inpatient status reviews made up the majority of recovery audits and …

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08.05.2015
When Conditions of Participation Don’t Matter
When Conditions of Participation Don’t Matter

During a recent discussion on Monitor Monday, my assertion that “the only inpatient criteria (is) the two-midnight rule” touched off a bit of a debate, because many others responded “not so fast, you are ignoring the conditions of participation!”  They’re right. I am.  When it comes to determining hospital status for Medicare, the conditions of participation aren’t relevant. To understand why, it...

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08.05.2015
RAC HMS Keeps on Fighting
RAC HMS Keeps on Fighting

HMS Holdings, the Recovery Auditor for RAC Region 4, announced last week that it had lost its third-party liability contract with the State of New Jersey. This is a significant loss. Estimates are that the contract contributed about $25 million in annual revenue. The winning contractor was Public Consulting Group, HMS Holding’s archrival with which it is embroiled in a...

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08.05.2015
Observation Notices: Coming Soon to Every Hospital
Observation Notices: Coming Soon to Every Hospital

Taking a cue from the medical industry, which has a knack for coming up with catchy acronyms for clinical studies,  the U.S. House of Representatives and Senate recently passed H.R. 876, The Notice of Observation Treatment and Implication for Care Eligibility Act – more commonly known as the NOTICE Act. This legislation was inspired by the great deal of attention given...

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08.05.2015
When the RACSs Attack? Write your Congressman and Fight Back!
When the RACSs Attack? Write your Congressman and Fight Back!

Two bills were recently introduced in Congress to address the growing backlog of hearings at the Office of Medicare Hearings and Appeals (OMHA). The first is H.R. 2156, the Audit Improvement Act, introduced by U.S. Rep. Sam Graves, R-Mo., which was referred on May 1 to the Subcommittee on Health. That’s the latest information on H.R. 2156, so sending a...

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CMS

$1.3 Billion Paid by Centers for Medicar…

David M. Glaser, Esq. | 06.15.2015

$1.3 Billion Paid by Centers for Medicare & Medicaid Services Clouds True Scope of Payout

On Thursday, June 11 the Centers for Medicare & Medicaid Services (CMS) quietly announced that as part of its 68-percent solution, it had paid out about $1.3 billion to 1,900...

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Feature Articles

CMS Announces Limits on Reviews by MACs …

Ronald Hirsch, MD, FACP, CHCQM | 08.17.2015

CMS Announces Limits on Reviews by MACs and QICs

Nothing is more frustrating to a provider than having a claim denied, preparing a comprehensive appeal, submitting that appeal, and then having the appeal denied – not because the appeal...

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IRF

CMS-13 Qualifying Diagnoses: Arthritis a…

Angela Phillips, PT - avatar Angela Phillips, PT | 03.04.2015

CMS-13 Qualifying Diagnoses: Arthritis as a Qualifying Condition

On Jan. 15, 2015 the Centers for Medicare & Medicaid Services (CMS) held a provider training call to address several key issues related to the IRF-PAI and the changes in...

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