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 …Read more
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 …Read more
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 …Read more
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...Read more
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...Read more
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...Read more
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...Read more
By attending this timely webcast, you will be made aware of the potential impact that the JW modifier can have on your organization and also know how critical documentation and medical necessity are to a successful transition.
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