Lack of auditor response leads to an ALJ hearing. “A stitch in time saves nine” is a pretty famous heuristic expression, but most people I know do not have any idea what it means. Simply stated, it means that taking the time to do something correctly now will save time…
OIG report cites widespread MAO problems related to denials of care and payment. Medicare and Medicaid are moving steadily into a capitated model system – or should I say, “have moved.” A central concern about the capitated payment model used in Medicare Advantage is the financial incentive for Medicare Advantage…
Document was reportedly not to be shared with providers An internal Centers for Medicare & Medicaid Services (CMS) memo on inpatient admission orders has come into possession of RACmonitor.  The memo, dated Oct. 3, was written to “clarify” the 2019 fiscal year Inpatient Prospective Payment System (IPPS) final rule for…
A brewing problem, or simply an area for clarification for IRFs?   During what was expected to be a plain vanilla review of the Inpatient Rehabilitation Facility Prospective Payment Systems (IRF-PPS) Coverage Requirements and Updates from the FY 2019 Final Rule, the Centers for Medicare & Medicaid Services (CMS) made…
OIG discusses plans in 2018 Work Plan update The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced on Thursday that the agency, along with the Centers for Medicare & Medicaid Services (CMS), has noted “problems” with upcoding in hospital billing to increase payment. As…
The Centers for Medicare & Medicaid Services (CMS) has informed state Medicaid directors that it intends to expand mental health treatment services via a new Medicaid demonstration project, the agency announced in a press release issued Tuesday. In a letter to the state Medicaid directors, CMS reportedly outlined existing and…
Highlights of the 2019 Medicare Physician Fee Schedule, released on Nov. 1, are provided by the author. There will be no change in E&M payment levels for 2019, as was proposed in the Centers for Medicare & Medicaid Services (CMS) proposed, rule, news that comes as a relief to many…
“Outpatient” does not equate “same-day.” By this time last year, the Centers for Medicare & Medicaid Services (CMS) had notified providers that they were removing total knee arthroplasty (TKA) from the Medicare inpatient-only list. While the cries of disbelief and howls of frustration eventually died down after a few months,…
Plaintiffs are the American Hospital Association and three other regional hospitals and healthcare systems. Providers with Medicare appeals pending may have their claims resolved sooner than expected. On Nov. 1, 2018, U.S. District Court Judge Boasberg ruled that the U.S. Dept. of Health and Human Services (HHS) must eliminate the…
Length of stay does not correlate directly with costs. I am sure many of you have heard me rant about observation rates before. I’m sure at least half of you have been told that your observation rate is too high and that you need to fix it. “You’re above the…