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Many MAOs have overplayed the significance of this decision. On Sept. 7, in federal district court in Washington, D.C., in a case in which the Medicare Advantage Organizations (MAOs) in the UnitedHealth Group family of companies sued Alex Azar, the Secretary for the U.S. Department of Health and Human Services…
This is the definition of “incident to” for supervision requirements in hospitals. A recent RACmonitor article focused on the level of physician supervision required when services are provided “incident to” an encounter in the clinic setting. This article will focus on the level of supervision necessary in the hospital, where…
CMS removed the admission order as a condition of payment effective Oct. 1, 2018. The change in the 2019 Inpatient Prospective Payment System (IPPS) Final Rule concerning the inpatient admission order has created more controversy than I expected. When I read the proposed and final rules, wrote my RACmonitor articles…
Know the risk, evaluate your exposure. The FY 2019 Inpatient Prospective Payment System (IPPS), which includes the Medicare Severity Diagnosis Related Groups (MS-DRGs), went into effect Oct. 1, 2018. There is one area that did not get much attention regarding the changes that were included in this year’s update: spinal…
Does healthcare IT really improve medical care? EDITOR’S NOTE: RACmonitor investigative reporter and New York attorney Edward Roche recently found himself in a life-threatening situation while on a business trip in Barcelona, Spain. Here, Roche recounts his story, the medical conditions to which he was a beneficiary, and the good…
New case law supports due process for Medicare providers. Due process is one of the cornerstones of our society. Due process is the universal guarantee and found in the Fifth Amendment to the United States Constitution, which provides "No person shall…be deprived of life, liberty, or property, without due process…
MAs are taking advantage of excessive denials to reduce payments to providers. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently found that between 2014 and 2016, a total of 75 percent of all appealed Medicare Advantage (MAs) denials were overturned, equivalent to roughly…
OMHA adds Chapter 14 to its case processing manual The Office of Medicare Hearings and Appeals (“OMHA”) has recently been updating its OMHA Case Processing Manual (“OCPM”). The OCPM was originally released in 2015 to regulate and codify procedures for adjudicative functions by using statutes, regulations, and OMHA directives as…