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 …Read more
“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 …Read more
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 …Read more
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...Read more
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...Read more
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...Read more
Tuesday, February 17, 2015
From a simple (inpatient) admission to the complex stratification of patient status that today characterizes the intricate web of observation, you will learn how to differentiate, capture and communicate inpatient versus outpatient care.
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