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Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness…
Payers and providers square off to ensure patients aren’t stuck with huge costs. EDITOR’S NOTE: Matthew Albright, chief legislative affairs officer for Zelis and the former Director of the Administrative Simplification Group of the Centers for Medicare & Medicaid Services (CMS), granted me an interview recently. What follows are excerpts…
OIG’s report to Congress profiles plenty of activity, including the ongoing battle against the opioid abuse epidemic. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is in the business of rooting out “fraud, waste, and abuse” in the nation’s healthcare system, to echo the…
Projecting results of an audit to a larger population of providers can be a serious step. Many of the organizations with which I engage feel this pressing need to use the results of individual provider audits to infer an overall pass/fail rate, either to everything that provider does or to…
Last week the Centers for Medicare & Medicaid Services (CMS) released a blog post from agency Administrator Seema Verma titled “Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork.” In the post, Ms. Verma talked about the Recovery Audit Contractor (RAC) changes CMS made back in 2015,…
Prices of certain drugs continue to spiral out of control as alternatives are sought. ol·i·gop·o·ly (äləˈɡäpəlē), noun: a state of limited competition, in which a market is shared by a small number of producers or sellers. I have been looking at data from the Centers for Medicare & Medicaid Services…
Surgery has a long history. Even as long ago as in ancient Egypt, we have found remains showing evidence of trephination, the boring of a hole in the skull for brain surgery. More than a century of experimentation in repairing the intestines without causing sepsis eventually was solved with a…
New guide offers the possibility of improving a hospital’s bottom line. Last week, The National Quality Forum and the American Hospital Association Center for Health Care Innovation released their how-to guide for hospitals and health systems seeking to implement, strengthen, and sustain tele-behavioral health. Entitled Redesigning Care, the guide outlines an…