Here’s a quick quiz. Imagine that a National Coverage Determination (NCD) lists six conditions for which a treatment is covered. During a review you find dozens of patients who received the treatment for a seventh, unlisted condition. Which of the following is true? You must refund every patient immediately. You must…
One million dollars: that is how much one hospital could have saved had it checked with a well-informed healthcare lawyer before making a voluntary refund. The client chose to refund the sum because its internal review department located hospital charts for which the physician had not certified the stay prior…
The first five years of the Recovery Audit Contractor (RAC) audit program created nightmares for many in the provider community. Deadlines were routinely missed at every step of the way. The appeal backlog at the Administrative Law Judge (ALJ) level exceeded three years and does not seem to be getting…
In our last article, we discussed trends in inpatient rehabilitation facility (IRF) audits and a noticeable increase in scrutiny of therapy services, particularly the intensity of therapy services. We are seeing IRF claims denied due to failure to meet the intensity-of-service requirement as well as when the preponderance of therapy…
Who complained?That might seem like a totally reasonable question. But it’s something that compliance officers might want to discourage from being asked. The issue was driven home for me recently when a client in the desert Southwest had an unpleasant interaction with a representative from the local licensing board. The board…
Early warning signs have revealed that the Centers for Medicare & Medicaid Services (CMS) will soon be launching an audit program for compliance with administrative simplification, according to Monitor Mondays special guest Matthew Albright, former director of the CMS Administrative Simplification Group, now vice president of legislative affairs for Zelis…
The Centers for Medicare & Medicaid Services (CMS) will be changing the criteria for short-stay audits in April, according to KePRO, one of the Medicare Quality Improvement Organizations (QIOs), which posted the announcement on its home Web page.“CMS is changing the selection process for medical records for short-stay reviews,” the…
When you get a request from a MAC, RAC, ZPIC, BISC or other entity in the alphabet soup of government contractors seeking records for an audit, what should you do?Do you immediately contact your legal counsel? Do you thoroughly review each of the records? This is an area where experts…
The word “stoned” is a 1960s slang word meaning roughly “intoxicated on illegal drugs.” The United States currently has an opioid epidemic. It has grown quickly, and now is of huge proportions. For the second time in only a few months, two U.S. parents were arrested because police found them…
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