Monday was the last day that CMS could have finalized the rule changes, per law. Three years ago this week, the hospital case management world was sent into turmoil by the release of CMS-3317-P, a 125-page Centers for Medicare & Medicaid Services (CMS) proposed rule titled “Revisions to Requirements for…
TPE audits appear to be on the rise. The old baseball adage, “three strikes and you’re out,” now has relevance in the Medicare audit arena. Targeted probe and educate (TPE) audits are the latest type of audits facing Medicare providers and suppliers. TPE audits are unique in that, unlike other…
Does healthcare IT really improve medical care? Today we present the first in a series of articles that will explore how information technology (IT) is one of the most egregious enablers of the high cost of medical care in the United States. This series is inspired by a recent hospitalization…
The final rule on provider-based clinics is expected in early November. To understand changes being made relative to provider-based clinics, both Federal Registers must be read, and due to the complexity of the language, studied with care. Note that these are proposed rule changes. We will have to wait until…
Chapter 8 changes appear to be less fair than ever before. “Life Isn’t Fair, but Government Must Be”— Former Texas Governor Ann Richards, 1991 Everyone has a plan until they get punched in the mouth, according to Mike Tyson, retired boxer and armchair philosopher. And it appears that the Centers…
Many MAOs have overplayed the significance of this decision. On Sept. 7, in federal district court in Washington, D.C., in a case in which the Medicare Advantage Organizations (MAOs) in the UnitedHealth Group family of companies sued Alex Azar, the Secretary for the U.S. Department of Health and Human Services…
This is the definition of “incident to” for supervision requirements in hospitals. A recent RACmonitor article focused on the level of physician supervision required when services are provided “incident to” an encounter in the clinic setting. This article will focus on the level of supervision necessary in the hospital, where…
CMS removed the admission order as a condition of payment effective Oct. 1, 2018. The change in the 2019 Inpatient Prospective Payment System (IPPS) Final Rule concerning the inpatient admission order has created more controversy than I expected. When I read the proposed and final rules, wrote my RACmonitor articles…
New case law supports due process for Medicare providers. Due process is one of the cornerstones of our society. Due process is the universal guarantee and found in the Fifth Amendment to the United States Constitution, which provides "No person shall…be deprived of life, liberty, or property, without due process…
OMHA adds Chapter 14 to its case processing manual The Office of Medicare Hearings and Appeals (“OMHA”) has recently been updating its OMHA Case Processing Manual (“OCPM”). The OCPM was originally released in 2015 to regulate and codify procedures for adjudicative functions by using statutes, regulations, and OMHA directives as…