By
At issue: hospital overpayments of $54.4 million. There has been recent talk on an online user group that many hospitals have had recoupments of payment for inpatient admissions from 2016 to 2018 due to an “incorrect discharge status code.” This appears to be in response to a November 2019 audit…
By
Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness…
By
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…
By
Issues abound in prominent payer coding guidance. By now, many hospitals have received denials for emergency department level-of-care coding. We could legitimately ask, “how did this happen?” Today we shall address how it started, why it’s important, and potential institutional responses. Denials for emergency care are not new. The spectrum…
By
Providers urged to review potentially eligible claims and consider participation in the expanded SCF process. The Office of Medicare Hearings and Appeals (OMHA) publicly implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process on June 15. SCF is an alternative dispute resolution process that provides appellants and the…
By
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…
By
Last week one of my clients in the southeastern United States got a series of letters from a collection agency following up on a situation that occurred nearly two years ago. Around that time, a company contracted with a state Medicaid agency audited this group and denied some claims because…