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Three risks, in particular, are expected to pose a greater liability for providers. As we get ready to say goodbye to another year of audits and investigations, compliance officers around the country have worked or are working to determine their audit elements for calendar year 2020, in response to the…
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As Virginia Medicaid behavioral healthcare providers are being terminated, the question remains, is it legal. EDITOR’S NOTE: The opinions expressed herein are exclusively that of the author and do not necessarily reflect that of RACmonitor. Virginia behavioral healthcare providers that accept Medicaid are under statewide blanket fire. Without warning or provocation,…
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Understanding why there’s a need for auditing the auditors. I frequently encounter complaints by healthcare providers that when they are undergoing Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), and, more recently, the Targeted Probe-and-Educate (TPE) audits, the auditors are getting it wrong. That’s as in, during a RAC audit,…
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MAC to audit physicians who prescribe opioids. It is well-known to the medical community and to the general public that the opioid epidemic has taken too many lives. The causes are myriad (I outlined these in a KevinMD.com article in 2016, the second most-read article of the year on that…
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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…
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I have whined in a previous RACmonitor enews article about how the importance given to the admission order in today’s healthcare industry makes absolutely no sense. It’s not an order for a medication or a test, wherein if it is transcribed incorrectly, the patient could be physically harmed. The admission…
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The CERT study gives one the opportunity to identify potential errors the same way that the auditors do. With nearly a million physicians in this country, how do auditing organizations determine who to audit? As of 2011, a total of 100 percent of Medicare fee-for-service claims started being passed through…
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Testing for compliance with the CMS-13 list of diagnostic categories can be down through presumptive methodology or medical review.
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Release of outdate guidelines raises fears that other MACs might adopt them to audit providers. The use of outdated definitions of malnutrition by a Medicare Administrative Contractor (MAC) is raising concerns that other MACs may adopt the same flawed practice. The universally accepted definitions, known as the American Society for…
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Should hospitals combine two admissions into one? In the absence of CMS guidance, hospitals are urged to do the right thing. Today I have a confession to make. For the last five years, I have been lying. Now, don’t get me wrong; I have not been doing it on purpose.…
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