December 12, 2019

Early Warning: Top Audit Risks for 2020

Three risks, in particular, are expected to pose a greater liability for providers. As we get ready to say goodbye to another year of audits and investigations, compliance officers around the country have worked or are working to determine their audit elements for calendar year 2020, in response to the…
December 5, 2019

Medicare Releases Jurisdictional Findings – Too Late to Help

By Timothy Powell, CPA CHCP
The biggest hurdle providers face is the prospective nature of the payment system. It was always a black hole. The Medicare Provider Reimbursement Review Board, or the PRRB, as it is commonly called, decided whether hundreds of Medicare cost report appeals would move forward or would be blocked for “jurisdictional…
EDITOR’S NOTE: CORRECTION:  In the RACmonitor Nov 29, 2019 edition, Dr. Ronald Hirsch noted that resource use data on skilled nursing facilities (SNFs) was not available on the SNF Compare website. Upon further investigation, the resource use data is, in fact, available indirectly from the SNF Compare home page. Subregulatory…
December 5, 2019

Medicare Advantage and the Saga of Scrutiny

By Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
The saga of increased scrutiny of Medicare Advantage plans continues to unfold. UnitedHealthcare’s SuspensionCMS announced a suspension of one year for the UnitedHealthcare H5322 contract for not reaching the mandatory 85percent medical loss ratio (MLR). Plans must achieve that magic medical loss ratio on an annual basis. For those unfamiliar…
December 5, 2019

Conditions of Participation Obligate Patient Participation

By Marvin D Mitchell, RN, BSN, MBA
Patient preferences: it’s not all that bad. The Medicare and Medicaid Conditions of Participation (CoP) Final Rule regulatory changes place the patient in the “driver’s seat” in directing their care. On the flip side, the new approach places an obligation on patients to participate. There is ample regulatory guidance available.…
Compliance is mandatory, but data from CMS remains unavailable at this time. The discharge planning day of reckoning is today, Black Friday, Nov. 29, 2019 – and yet, as of this reporting, the only source of data, the Centers for Medicare & Medicaid Services (CMS) Compare website, still has no…
November 27, 2019

Discharge Planning Conditions of Participation Final Deadline Approaching

By Mary Beth Pace, RN, BSN, MBA, ACM, CMAC
Final rule becomes effective Friday, Nov. 29, 2019 EDITOR’S NOTE: The following are edited remarks by Mary Beth Pace, the author who was a panelist on Monitor Mondays Nov. 25, reporting on how Trinity Health is preparing to implement the final rule on discharge planning conditions of participation from the…
November 21, 2019

Price Transparency: Two Rules for the Same Issue

By Stanley Nachimson, MS
One rule is proposed; the other is now the final rule on price transparency. The Centers for Medicare & Medicaid Services (CMS) recently issued two rules intended to increase the transparency of pricing in the healthcare system, continuing its efforts to provide patients with more data to make informed decisions…