ED physicians and healthcare providers are a distinct breed – whales in a sea of fish. After all, emergency room doctors have, for the most part, been overlooked by the Recovery Audit Contractor (RAC) auditors (or TPE, Targeted Probe-and-Educate; ZPICs, Zone Program Integrity Contractors; or Medicare Administrative Contractors, MACs). Maybe…
CMS launches healthcare outcomes challenge. Expect more artificial intelligence (AI) in healthcare in 2020. We will see AI used primarily in diagnostics and auditing. In each of these areas, AI promises to impose drastic changes on society. As these changes reverberate through organizations, old work patterns will be disrupted. In…
The Low Income Pool or “LIP” is a funding pool designed to support health care providers that provide uncompensated care to Florida residents who are uninsured or underinsured.  There are multiple states with similar programs. CMS approved the LIP in 2005 as part of a section 1115 demonstration project (usually…
A regulation states you may not appeal a decision by a contractor. During a recent Monitor Monday broadcast, a listener questioned whether it is permissible to challenge the decision to reopen a claim during an audit. The listener’s question is an astute one that hearkens back to a troubling case…
The federal watchdog did not, however, decide to demand recoupments. It is said that great minds think alike. And that proved to be true when the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released its report (CMS improperly paid millions of dollars…
The total denial per claim can run in the tens of thousands of dollars. Chuck Buck has asked me to share with you our experiences here at the University of Wisconsin regarding so-called “forensic” audits done on our outlier claims, which we are receiving from a review firm called Equian.…
CMS squeaks by with B-plus in OIG audit. If the Centers for Medicare & Medicaid Services (CMS) received a grade for its audit performance during the 2015 and 2016 fiscal years, it would have been about a B-plus, maybe waived up to an A-minus, according to an announcement made recently…
Expect more mass production of audits. Looking forward to the remainder of 2019, we will see a number of exciting information technologies (IT) that will reshape healthcare and Medicare. These include artificial intelligence (AI), the cloud, DNA sequencing, in silico testing of new molecular entities (NMEs), and distributed ledger systems,…
The PIM is a woefully inadequate guide for audits leveraging extrapolation. EDITOR’S NOTE: This is the fourth in a series of reports on alleged bias the author has uncovered in extrapolation audits. This is part four of a three-part series expressing my disappointment in chapter 8 of the Medicare Program…
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…
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