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Federal takedown is considered the largest healthcare fraud in history. The Department of Justice (DOJ) has charged hundreds of medical professionals in what was dubbed “the largest healthcare fraud takedown operation in American history.” The DOJ brought charges against 601 defendants (76 of whom are doctors) for their alleged participation…
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Facilities that received a notice of non-compliance and believe the notice is in error must respond by Aug. 7, 2018 The Centers for Medicare & Medicaid Services (CMS) announced on July 6 that notifications to facilities that were determined to be out of compliance with the Inpatient Rehabilitation Facility (IRF)…
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CMS proposes major changes to E&M guidelines. Well, we have heard it for years: evaluation and management (E&M) guidelines need an overhaul. And now we have a proposal on the table. Before we get into the proposed changes, think for a moment: if you had full autonomy, how would you…
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The 340B drug pricing program has suffered a major setback. The axe fell on the American Hospital Association (AHA) and on hospitals across the country when the U.S. Court of Appeals dismissed a key AHA lawsuit on Tuesday. Following what can only be called a tempestuous journey, the fight against…
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Unique opportunity. Hospitals urged to use great discretion. The Centers for Medicare & Medicaid Services (CMS) wants to know if your total knee replacement (TKR) claims have been denied. Ronald Hirsch, MD, made the announcement today during the weekly broadcast of Monitor Mondays when he reported that he has received…
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CMS proposes to change physician evaluation and management (E&M) coding with a drastic overhaul. After soliciting comments from many stakeholders in the last year, the Centers for Medicare & Medicaid Services (CMS) has just proposed sweeping changes to the way physicians bill for evaluation and management (E&M) services in the…
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If there is a pattern of inappropriate denials, report it to your CMS regional office  Are all of you refreshing your browser every 15 minutes waiting for the Centers for Medicare & Medicaid Services (CMS) to release the Outpatient Prospective Payment System (OPPS) proposed rule? I didn’t think so. But…
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Better ED quality measures, and, ultimately, greater patient satisfaction are among benefits cited. The placement of registered nurse (RN) case managers in the emergency department, with a focus on determining appropriate admission status and making status recommendations to admitting physicians, has proven to be very successful at Waukesha Memorial Hospital…
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Providers urged to review potentially eligible claims and consider participation in the expanded SCF process. The Office of Medicare Hearings and Appeals (OMHA) publicly implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process on June 15. SCF is an alternative dispute resolution process that provides appellants and the…
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The whistleblower brought this suit under the federal False Claims Act. In February 2014, whistleblower Sarah Benhke, the former senior Medicare Part D actuary at Aetna, filed a sealed complaint against CVS Caremark, the pharmacy benefit management department of healthcare giant CVS Health, accusing the company of billing Medicare Part…