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The Government Accounting Office (GAO) today issued a report citing what it described as “weakness” in addressing vulnerabilities to improper payments, while acknowledging that improvement had been made to contractor oversight.
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Now, “payment-recapture audits” are on their way, thanks to the healthcare reform legislation (officially known as the Patient Protection and Affordable Care Act), which President Obama signed into law on March 10. In a nutshell, here’s the plan: No...
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In a decision dated February 1, 2010, the Medicare Appeal Council, which presides over the 4th level of RAC appeals, issued a judgment that could seriously alter the impact of RAC medical necessity audits and recoupments.
Clausen Krzywicki, one of th...
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ED. NOTE: This is the conclusion to Carol Spencer’s article on MS-DRG Validation and Data Analytics. Part I appeared in RACMonitor.Enews on March 18, 2010 and is currently posted on the RACMonitor Web site.
There are both internal and external tri...
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More High Volume, High Dollar Value DRGs
The Region C RAC, Connolly Healthcare, posted 25 new DRG Validation Issues to their list of CMS-Approved audit issues, on Tuesday, March 16 plus another five (5) on Friday, March 19. Once again, Connolly...
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Connolly Consulting Associates, the recovery audit contractor (RAC) for Region C, recently added another 25 MS-DRG validations to its approved list of issues. This brings its total to 104 MS-DRGs. Of the newly released MS-DRGs, 22 out of the 25 are surgic...
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CMS recently announced that it would be continuing its Program for Evaluating Payment Patterns Electronic Report (PEPPER) initiative.
You may recall that these very informative reports were produced quarterly by CMS until 2008. One of the stated goal...
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There are several questions you'll need to ask before beginning the worthwhile endeavor called data analytics.
What are data analytics? Why perform data analytics before I perform a MS-DRG validation audit? What steps should I take to perform d...
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The Deficit Reduction Act of 2005 provided the resources to establish the Medicaid Integrity Program (MIP), the first national strategy in the 40-year history of the Medicaid program to promote the fiscal integrity of Medicaid by detecting and preventin...
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The RACs will now be responsible for referring to CMS any cases of potential fraudulent activity identified during the course of their own improper payment investigations.
Last week, the U.S. Department of Health and Human Services' Office of Inspect...
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The week of March 15 - the ides of March - is when, in a nanosecond, Marcus Junius Brutus and others stabbed the Emperor Julius Caesar to death in the Roman Senate in 44 B.C. Were it not for the soothsayer who previously had warned Caesar to "beware the i...
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We all suspected it, but now it's official: RACs will be providing information to CMS for follow-up on cases of possible fraud. In February, Inspector General Daniel Levinson issued a report titled "Recovery Audit Contractors' Fraud Referrals." The report...
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In January CMS posted two new questions and answers on its FAQ Web site: numbers 9973 and 9974. Both of these relate to hospital outpatient observation services, which has been a problem area for two decades.
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Clinical and administrative staff at many organizations are struggling with the issue of what "medically necessary" really means - even those who have reviewed the Medicare Benefit Policy Manual (MBPM), Chapter 8, section 20.1 Three-Day Prior Hospitalizat...
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U.S. ambulance providers generated about $9 billion in revenue in 2009, according to information gathered by Hoover's, Inc., which offers proprietary business information through the Internet and other online services. Of that amount, hospital-based amb...
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Little did I know when I e-mailed one of the authors of a Feb. 3 article in RACMonitor (Is It Worth the Effort to Rebut RAC Findings: 10 Steps for a RAC Discussion) that my comment would turn into a discussion and now an article of my own on the differe...
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Now that the RAC audits are in full swing, providers may be wrestling to understand the new discussion period and the implications for choosing to exercise this new option and when they should actually consider initiating a discussion period.
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By Chuck Buck and Dennis JonesContributing editor Dennis Jones certainly felt as if he was on the other end of the query process when providers were querying him during Monitor Monday's podcast earlier this week.
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