December 12, 2019
By Sean M. Weiss, CEMA, CMCO, CPMA, CPC-P, CMPE, CMPM, CPC-P Early Warning: Top Audit Risks for 2020
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…
September 18, 2019
By Knicole C. Emanuel Esq. Exclusive: Termination Underway for Virginia Medicaid Behavioral Healthcare Providers
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,…
June 27, 2019
By Knicole C. Emanuel Esq. RAC Audits: Alternatives to Litigation
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,…
February 7, 2019
By Ronald Hirsch, MD Physicians and the Opioid Crisis
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…
November 29, 2018
By Frank D. Cohen, MPA, MBB A Stitch in Time: An Indictment of the CMS Appeals Process
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…
August 30, 2018
By Ronald Hirsch, MD QIOs Urged to Stop Denials for Lack of Timely Authentication
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…
By Frank D. Cohen, MPA, MBB
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…
November 9, 2017
By Angela Phillips, PT Presumptive Compliance for IRFs: Are You Facing A Desk Audit?
Testing for compliance with the CMS-13 list of diagnostic categories can be down through presumptive methodology or medical review.
October 27, 2017
By Ronald Hirsch, MD Novitas Guidelines for Malnutrition Reported to be Outdated, not Useful for Physicians
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…
October 19, 2017
By Ronald Hirsch, MD Hospital Admissions: Combining Two into One Doesn’t Add Up
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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