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Congress appears to be closer on a COVID-19 relief package. U.S. Supreme Court Associate Justice Ruth Bader Ginsburg passed away on Friday. Ginsburg was the second woman appointed to the Supreme Court, serving there for 27 years. We mourn her loss, and as a country, we are grateful for her…
Two payers allegedly inflated their bids. Earlier this month, two Independence Blue Cross (IBC) subsidiaries in Pennsylvania agreed to pay $2.25 million to resolve allegations that they defrauded the Medicare Advantage (MA) program and violated the False Claims Act by improperly inflating their bids. Medicare Advantage, also known as Medicare…
The Centers for Medicare & Medicaid Services (CMS) recently announced updates to the 2021 Medicare Physician Fee Schedule (MPFS). Among them are unprecedented increases in relative value units (RVUs) associated with office-based evaluation and management (E&M) visits. Under these changes, CMS will reimburse a greater number of RVUs. Then, in…
Providers forced to camouflage in mediocrity.  EDITOR’S NOTE: This the first in a series of articles that explores the use of algorithms in the auditing of medical claims. The Centers for Medicare & Medicaid Services (CMS) has pioneered the use of computer algorithms for detection of fraud. These efforts leverage technologies…
In the world of private insurance, it’s the contract that controls. Recently, as I was speaking with one of my colleagues who specializes in reviewing and negotiating agreements with third-party payers, she lamented that no one reads their provider agreement anymore.  I fear that she may be right.  Reading a…
Presidential Executive Order No. 1 was issued on Oct. 20, 1862 by President Lincoln; it established a wartime court in Louisiana. The most famous executive order was also issued by Lincoln a few years later – the Emancipation Proclamation. Executive orders are derived from the Constitution, which gives the president…
The Unified Program Integrity Contractors (UPICs) may need lessons in reading patient notes. Should they be "defunded?" These days, everyone has a horror story about an audit. There are arrogant know-it-alls that show up unexpected, embarrassing the provider in front of their patients. "He must have done something wrong, otherwise…
Dear hospital administrator/provider who believes you comprehend how terrible the no-visitor policy is: You don’t. Having practiced as a pediatric hospitalist for a decade, I’ve participated in thousands of conversations with patients and family members wherein my goal was to be as straightforward as possible. I try to stick to…