Ronald Hirsch, MD, FACP, CHCQM | January 28, 2015

Three Requirements to Meet Outlier Certification

Recently I reported here on RACmonitor about all the uncertainty regarding the new requirements for outlier certification that replaced the admission certification requirements. As you may recall, the Centers for Medicare & Medicaid Services (CMS) view was much more liberal than the interpretation from one of the Medicare Administrative Contractors (MACs). Fortunately, I have been able to follow up with CMS and have some good news – CMS does not have …

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Gracielinda Prescott | January 28, 2015

Return of the RACs

The song “Return of the Mack” by Mark Morrison has played randomly in my head since earlier this year, when the Centers for Medicare & Medicaid Services (CMS) announced the limited return of Recovery Auditor program. I just make one slight change to the song’s chorus: “return of the RACs.” The program has been dormant since June 1, 2014, when current audit contracts expired. Though the program will eventually make its …

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Frank Cohen, MPA | January 28, 2015

2015: The Lion is at the Door

From my perspective, 2014 went out like a lion and 2015 has come in the same way, at least as far as post-audit extrapolation work goes. Several weeks ago I picked up four new cases, and two of those (as have been a few others in the past) involve physicians who have split their interests between clinical practice and durable medical equipment (DME). It seems that DME continues to be a …

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01.14.2015
Be Prepared: Patient Eligibility Must Support Home Health Claims
Be Prepared: Patient Eligibility Must Support Home Health Claims

The Recovery Auditor (RAC) and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2015 work plans will focus on compliance with patient eligibility criteria, which must support home health claims for services.  The OIG will also be looking to verify that home health agencies (HHAs) conduct timely criminal background checks for all employees and contractors, as...

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12.17.2014
Medicare Myths: Common Misperception about Medicare Billing Rules
Medicare Myths: Common Misperception about Medicare Billing Rules

 Which of the following are true?   •  The Medicare Administrative Contractor (MAC) has complete legal authority to determine whether a service is medically necessary. •  You must bill exactly the same charge to all patients who receive the same service.  •  It is an overpayment if a note is not signed.  •  Nurse practitioners and physician assistants can’t bill for high-level visits. •  If it...

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12.17.2014
DEVELOPING STORY: New Home Health Requirements Ease Burden on All
DEVELOPING STORY: New Home Health Requirements Ease Burden on All

On Dec. 16, the Centers for Medicare &Medicaid Services (CMS) presented an open door forum on the new home health certification requirement that becomes effective on Jan. 1, 2015. The 2015 Home Care Prospective Payment Final Rule, CMS-1611-F, made significant changes to the face-to-face requirement that was mandated by the Patient Protection and Affordable Care Act (PPACA). Noting that the improper...

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12.17.2014
What’s Hot and What’s Not: 2014 Analytics in Review
What’s Hot and What’s Not:  2014 Analytics in Review

By most accounts, 2014 was a tumultuous year for healthcare providers. The administrative law judges (ALJs) suspended the scheduling of hearings while the Centers for Medicare & Medicaid Services (CMS) suspended Recovery Auditor (RAC) audits due to contractual disagreements with the RACs themselves. Reversal rates on appeals skyrocketed and to help clear up the backlog, CMS offered a limited number...

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OIG

Mandatory Reading: 2015 U.S. Department …

Elizabeth Lamkin, MHA | 11.05.2014

Mandatory Reading: 2015 U.S. Department of Health and Human Services Office of Inspector General Work Plan is Published

  As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should...

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Feature Articles

Last Rites for Inpatient Admission Certi…

Ronald Hirsch, MD, FACP, CHCQM | 12.17.2014

Last Rites for Inpatient Admission Certification

Over the years I have heard many say that they would like to be able to attend their own funeral, so for the last update of the year, I thought...

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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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