What’s next for auditing professionals? The first thing to note here is that I am not an auditor.  So, for me to write an article on auditing tips might seem a bit unusual. But this is not an article on auditing compliance, but rather on being an auditor – and…

A short lesson on game theory. Last week on Monitor Mondays, Knicole Emanuel, Esq. reported on the case of Commonwealth v. Pediatric Specialist, PLLC, wherein the Recovery Audit Contractors’ (RACs’) experts were prohibited from testifying because they were paid on contingency. This means that the auditor (or the company for…

EDITOR’S NOTE: While presenting at the recent New England Healthcare Internal Auditors (NEHIA) annual conference in Connecticut, Knicole Emanuel encountered the recurring audit topic of positive airway device supplies or PAPs. The following is her report. Back in 2014 and 2015, then again in 2018, PAPs were the main area…

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…

Oct. 1, 2019 marks the beginning of a new era of billing for skilled nursing facilities (SNFs). Say goodbye to RUG-IV, and hello to the Patient-Driven Payment Model (PDPM). This is a daunting task, not for the faint of heart. Under PDPM, reimbursement for Medicare Part A patients in SNFs…

There are now 200,000 new targets for CMS and private payers. Since the first of this year, I have engaged in several audits for which the target is not the physician, but rather a physician’s assistant (PA) or a nurse practitioner (NP). While there have always been audit issues regarding…

CMS has posted three new issues the RACs have proposed for auditing, pending CMS evaluation and approval. Last week the Centers for Medicare & Medicaid Services (CMS) created a new page on its Recovery Audit Contractor (RAC) website titled Provider Resources. CMS indicated that it will post on this page…

Recent articles have described the regulatory complexity surrounding signatures and credentials in the world of healthcare. There’s a practical question associated with this: How do you train people to comply with a best practice without mischaracterizing the state of a law?  This question is really important. Perhaps my favorite activity as a lawyer…

The topic of Condition Code 44 is not new. Detailed by the Centers for Medicare & Medicaid Services (CMS) in September 2004 via MLN Matters SE 0622, titled Clarification of Medicare Payment Policy When Inpatient Admission is Determined not to be Medically Necessary, Including the Use of Condition Code 44:…

According to Patti Smith, the American laureate of punk rock, “You can't carve up the world. It's not a pie.” Perhaps you cannot carve up the world but Medicare has proposed carving up—or more accurately, carving in—the hospice pie to Medicare Advantage (MA) programs. To appreciate the potential import of…