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…
A False Claims Act case pits a prominent health system against its EHR software provider. Over the last many years, healthcare providers have been financially incentivized to purchase electronic health records (EHR) software. These programs can cost upwards of $25,000 to $50,000, and, sometimes are renewable every year. In other…
UHC bulletin excerpt underscores necessity of close scrutiny. In the June 2017 UnitedHealthcare (UHC) network bulletin, there was an article that addressed UHC’s decision to no longer pay for consult services. We addressed this in previous audit tips and articles created by our team, but the other issues that must…
The surprise is approval for RACs to audit admissions to inpatient psychiatric hospitals for medical necessity for inpatient psychiatric care. As we all know, all the Recovery Audit Contractors (RACs) are going full steam ahead with all their approved issues. And new issues are being added to the list on…
The primary function of the hospital business office is to submit, process, and collect payment for healthcare claims. To complete these tasks effectively, millions of medical records are sent to third-party payers by business office personnel every year. These business office disclosures occur during the claims submission process or as…
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