News

Providers urged to review potentially eligible claims and consider participation in the expanded SCF process. The Office of Medicare Hearings and Appeals (OMHA) publicly implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process on June 15. SCF is an alternative dispute resolution process that provides appellants and the…
The whistleblower brought this suit under the federal False Claims Act. The False Claims Act (FCA) allows a private party (known as a “relator” or “whistleblower”) with inside information about fraud against the government to file a lawsuit on the government’s behalf and receive 15 to 30 percent of the…
If a patient does not have liability for a particular expense, the insurer is similarly absolved of responsibility. The June 14 issue of RACmonitor focused in part on Anthem’s policy regarding coverage of ED services. The relevant article suggested that insured patients should not face responsibility for emergency room bills.…
Observation is a service, not a status. As we have all seen in recent events on television, choice of words matters. That’s particularly true in the utilization review world. And one word that matters an awful lot is “observation.” I am sure you have all heard this a million times…
The whistleblower brought this suit under the federal False Claims Act. In February 2014, whistleblower Sarah Benhke, the former senior Medicare Part D actuary at Aetna, filed a sealed complaint against CVS Caremark, the pharmacy benefit management department of healthcare giant CVS Health, accusing the company of billing Medicare Part…
The PIM is a woefully inadequate guide for audits leveraging extrapolation. EDITOR’S NOTE: This is the third in a series of reports on alleged bias the author has uncovered in extrapolation audits. In my last two articles, I addressed several of the reasons I feel Chapter 8 of the Program…
Anthem’s ED policy prompted a Missouri law that defines a medical emergency. The Upshot column in the New York Times on May 19 focused on Anthem’s experiment with denying emergency room visits, arguing that patients should have known that ED care was unnecessary.    One of the anecdotes in the…
Federal entities are beginning to pay closer attention to hospitals’ financial wellness. Last week was Revenue Integrity Week, which marked an opportunity to acknowledge the work of the many people in health systems’ hospitals who help get a claim paid. I am always amazed that they can take our often-illegible…