Featured Article

Protecting patient rights is one of the cornerstones of Medicare policy. As a doctor, I can assure you that I would rather patients concentrate on their health and not worry about whether their medical providers or their insurers are making decisions for them based on considerations that are not in…
July 25, 2019

Legal Risks for Case Managers Highlighted at 2019 CMSA Conference

By Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV
Case managers could be at risk relative to discharge planning. While not significantly common, hospital case managers have been named in nursing malpractice suits, primarily in association with discharge planning. Attorneys Jessica L. Gustafson, Esq. and Abby Pendleton, Esq. from The Health Law Partners, P.C. discussed this issue and other…
An interview with a subject matter expert sheds light on one of healthcare’s trendiest topics. Editor’s Note: Ellen Fink-Samnick is a member of the RACmonitor editorial board and a permanent panelist on Monitor Mondays whose areas of expertise include the social determinants of health (SDoH). Chuck Buck recently conducted an online interview with…
Swing vote by Chief Justice John Roberts reflects his support of judicial precedent. On June 26 the U.S. Supreme Court issued a decision (https://www.supremecourt.gov/opinions/18pdf/18-15_9p6b.pdf)  on how courts should handle ambiguous government regulations.  Many people, including me, expected that the case would change the level of deference courts grant to a…
OMHA’s new eligibility requirements are intended to benefit more providers. The Office of Medicare Hearings and Appeals (OMHA) has expanded its Settlement Conference Facilitation (SCF) program, and it is now open to the appellant community. By way of background, Settlement Conference Facilitation (SCF) is an alternative dispute resolution process designed…
June 20, 2019

IRF Count Down Continues: Part II

By Angela Phillips, PT
There’s an updated version of the IRF-PAI manual. As we prepare for changes in how inpatient rehabilitation facilities (IRFs) are paid through the utilization of quality indicator data rather than Functional Independence Measure (FIMTM) scores to classify patients into appropriate case-mix groups (CMGs), it’s important that IRFs provide the most…
June 13, 2019

My Patient is Bad – Very Bad

By Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®
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…