Hospitals may consider abandoning their contracts. There are few things managed Medicare plans have come up with that are more unfair to hospitals than denials due to readmission. Hospitals with contracts with managed Medicare payers often must endure these denials, as they are not often excluded in contracts. Managed Medicare…
Weighting changes will be implemented for the 2019 calendar year. Important changes for the 2019 calendar year in healthcare include Merit-Based Incentive Payment System (MIPS) category weighting changes. The quality category will decrease in importance, with a shift of 5 percent, going from 50 to 45 percent of the overall…
The debate over the controversial two-midnight rule rages on. Ok, I surrender. “This is not the hill I intend to die on” is an accurate metaphor. There has been here at RACmonitor a flurry of concern, debate, troubled investigation, and notice of dodging by health plans, and, as we’ve come…
New CMS pharmacy dashboards include data sets from 2013 to 2017. The Centers for Medicare & Medicaid Services (CMS) has released its latest “CMS Drug Spending Dashboards.” While the dashboards are interactive (you can look up specific drug data), we took a broader approach and downloaded and analyzed the source…
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…