WASHINGTON, D.C. - As of January 2011 the Centers for Medicare & Medicaid Services (CMS) had failed to resolve or even take any meaningful action to address 77 percent of vulnerabilities identified by contractors in 2009, according to a recent study b...
Two hospitals have settled allegations of overcharging the government for infusion therapy and lithotripsy services, the U.S. Attorney for eastern California announced Dec. 7.
Sutter Health Association paid more than $1.4 million for the 25 nor...
Inpatient hospitals are improperly coding coronary bypass with percutaneous transluminal coronary angioplasty (PTCA) with major complications and comorbidities (MCCs) (MS-DRGs 231, 233, and 235), according to the October issue of the Medicare Quarterly Pr...
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HealthDataInsights, the RAC for Region D, posted five issues for inpatient hospitals last week. HDI cited CMS’s Medicare Benefit Policy Manual chapter one (Inpatient Hospital Services Covered Under Part A) and chapter...
EDITOR'S NOTE: This is the third installment of a four part series on Utilization Management Plan.
The heart of a good utilization management (UM) plan gives operational direction to the case management team and physician advisors performing the util...
Enrollment in the Medicare program progressively has become more involved over the years. This process is accomplished through the use of various CMS-855 forms. On July 1, 2011 CMS quietly updated the CMS-855 system and switched from five different ...
The OIG in 2012 will continue to address previous years' problem areas, but it currently appears to be taking a closer look into physician billing, specifically the use of modifiers that impact reimbursement.
In the 2011 Work Plan, the OIG identified...
This part of the year is particularly harsh for people who lack housing.
If not employed, the days are often spent looking for a warm place to rest, nutritious and warm food to nourish the body, and above all, a place to stay for the night....
A New Jersey doctor has been sentenced to more than three years in prison after sending people posing as physicians to perform more than 20,000 patient visits.Some of the people that Yousuf Masood, 47, of Warren, N.J., had po...
As many of you are aware, CMS unveiled the Part A-to-Part B Rebilling Demonstration Program on Nov. 15.
CMS has released general information about the program, including that it will allow a specific number of hospitals (selected on a first-come, fir...
As has become their custom, CMS has released the data on Medicare RAC collections for the last quarter, along with a supplemental report for the entirety of fiscal year (FY) 2011.
For the final quarter, the recovery auditors identified $353.7 mil...
In the updated RAC Statement of Work released back in September, we saw the semi-automated review method codified as a legitimate audit tool for the first time. Yet the dangers of this method to the provider community, if we fill in some rather prominent ...
By Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq.
On Nov. 15 CMS unveiled a demonstration program that may provide some relief to hospitals whose inpatient claims are being denied as not medically necessary because care was not provided...
Provider errors, unallowable services and insufficient documentation caused Medicare to overpay for outpatient services, according to the Office of Inspector General’s Semiannual Report for April through September.
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Reducing avoidable readmissions rapidly is becoming one of the biggest hot-button issues for hospitals, and it’s a matter that involves both medical necessity compliance and patient care concerns.
The Centers for Medicare & Medicaid Services...
Recovery auditors will examine claims before they are paid as part of a new demonstration starting Jan. 1.
The prepayment audits, which CMS announced Nov. 15, will conduct those audits on “certain types of clai...
WASHINGTON, D.C. – Workload data used by the Centers for Medicare & Medicaid Services (CMS) to oversee its Zone Program Integrity Contractors (ZPICs) is not uniform and at times inaccurate, factors creating data access issues affecting the contracto...
EDITOR’S NOTE: Last week on Monitor Monday, our weekly poll asked listeners if they were satisfied with their RAC’s outreach efforts. Only 10 percent said they were “satisfied and well informed.” Thirty-four percent responded that they were “n...
EDITOR’S NOTE: This is the second of a three part series on Utilization Management Plan.
Did you know that the utilization review committee (URC) is the only committee required by the Medicare Conditions of Participation? Did you know the URC is...
