Part II continues to explain the nuances in the changes made by CMS to its statistical sampling methodology. The Centers for Medicare & Medicaid Services (CMS) recently made significant changes in its statistical sampling methodology for overpayment estimation. Effective Jan. 2, 2019, CMS radically changed its guidance on the use…
UnitedHealth Group and MEDPAC both reported on the state of emergency departments last week. Last week, emergency departments (EDs) got some serious national attention. First, UnitedHealth Group released a study examining costs associated with freestanding emergency departments (FSEDs), and second, there was a call for the Centers for Medicare &…
Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC). Extrapolation is a veritable tsunami in…
Contrary to the belief of some, the rule remains alive and well. EDITOR’S NOTE: The rumor mill was churning recently regarding news from a Wisconsin health plan that reportedly was discontinuing adherence to the contentious two-midnight rule of the Centers for Medicare & Medicaid Services (CMS), believing that CMS was,…
Medicare has not been paying its fair share of medical costs for decades. Medicare for all: what would it do to hospitals? Hospital CFOs tell us that Medicare does not pay as much as other payers, and that Medicare for all would result in many hospitals closing. To answer this…
The ADR rule went into effect Jan. 1, 2019 The Centers for Medicare & Medicaid Services (CMS) has updated its criteria for additional development requests (ADRs). If your ADR “cycle” is less than 1, CMS will round it up to 1. When a claim is selected for medical review, a…
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.…
Balancing patient advocacy with access to Part A Medicare skilled nursing benefit. The ambiguities of Medicare regulations often create conundrums for case managers and physician advisors as we try to advocate for our patients while remaining compliant. One area that often creates a dilemma in balancing patient advocacy with compliance…
Decision expected soon in the Providence lawsuit. As regular Monitor Monday listeners know, we have been closely tracking the progress of data analysis firm Integra Med Analytics’ whistleblower lawsuit against Providence Health and its consultant J.A. Thomas and Associates, Inc. (JATA), alleging a conspiracy between Providence and JATA to upcode…
The controversy continues over hospitals denied authorization to transfer patients to LTACHs. It is my long-held opinion that health insurance companies exist to not pay claims. They are an investment tool for the investment class. The plutocracy has never acted in its own long-term best interests. In few places is…