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A culture of compliance is the key to success. There are no indications that audits of healthcare entities by government payers are slowing down – if anything, the ramping up of audit operations that was hinted at a short while ago has indeed materialized. Commercial payers are moving just as…
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Never ignore a request for records by the single-state agency in your state. One of the best examples that illustrates the importance of the “single state agency” involves a Medicaid fraud scheme in Illinois involving four women. It’s a real-life Bonnie and Clyde – if Bonnie and Clyde stole healthcare…
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The pandemic continues to impact Medicare reimbursement. COVID-19 continues to make news on the regulatory front with two new directives from the Centers for Medicare & Medicaid Services (CMS), centering on testing for the deadly coronavirus and formal coding edits for the Medicare Administrative Contractors (MACs) on payments with the…
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Opdivo is an immunotherapy treatment for advanced cancer. What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover…
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Providers forced to camouflage in mediocrity.  EDITOR’S NOTE: This the first in a series of articles that explores the use of algorithms in the auditing of medical claims. The Centers for Medicare & Medicaid Services (CMS) has pioneered the use of computer algorithms for detection of fraud. These efforts leverage technologies…
February 27, 2020

The New World of Auditing

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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…
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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…
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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…
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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…
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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…