March 12, 2020
By Holly Louie, RN, BSN, CHBME
More Major Insurance Plans Using Proprietary Tactics to Deny Medically Necessary, Correctly Coded Services
Some providers are experiencing high-volume denials based on idiosyncratic edits, made-up rules, and black-box edits. I have lost count of the number of publications released this year addressing surprise billing, incorrect use of Modifier 59, over-documentation, note bloat, billing for unnecessary services, over-prescribing of opioids, and myriad other topics targeting…
October 17, 2019
By Marvin D Mitchell, RN, BSN, MBA
Decision-to-Admit to a SNF Remains a Documentation Challenge
Documentation is essential in order to avoid RAC problems. On the Sept. 9 edition of Monitor Mondays, Dr. John K. Hall made an excellent presentation on the coming Recovery Audit Contractor (RAC) audits of skilled nursing facility (SNF) decision-to-admit proof of skilled need, and how hospital documentation is essential to…
September 26, 2019
By David M. Glaser, Esq.
Court decision upholds provider sovereignty over determinations of medical necessity: Part II
The ruling focused on key hospice admissions. A recent RACmonitor article focused on the AseraCare case, wherein the 11th Circuit Court of Appeals concluded that if reasonable physicians differ about the medical necessity of care, a claim can’t be false. There were two other elements of the case worth emphasizing.…
June 13, 2019
By Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®
My Patient is Bad – Very Bad
Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness…
May 16, 2019
By Marvin D Mitchell, RN, BSN, MBA
MA Plan Denials. Now What?
There are steps providers should take for holding managed care plans accountable. Considerable effort is regularly devoted by healthcare providers to overcome coverage denials through the application of the governing rules, such as they can be leveraged. Following the rules is tough in a world where money talks, bringing us…
April 12, 2018
By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer
Advice for Coding Medical Necessity on Outpatient Claims
Don’t confuse your payer policy with providers’ medical degrees My recent article regarding secondary diagnosis coding and my advice to “just follow the guidelines” seems to have touched a nerve. Because it’s never quite that simple, is it? There’s the textbook answer on how we should be coding, and then there’s…
By David M. Glaser, Esq.
Bad advice tends to circulate regarding how to select the correct E&M codes. At a recent oncology conference in California, the speaker before me erroneously declared that the level of medical decision-making always controls the selection of code for any evaluation and management (E&M) service. She confidently asserted that…
December 21, 2017
By Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV
Keeping Empathy from Trumping Medical Necessity
Determining when and how to discharge adult patients can present some difficult dilemmas. When I was a medical student (not that long ago,) my instructors emphasized a clear message over and over: decisions about patient care should never be tainted with consideration of cost. When I entered residency, however, things…
December 7, 2017
By David M. Glaser, Esq.
Challenging the Credibility of Experts in Cases of Medical Necessity
There are lessons to be learned from challenging the credibility of experts in medical necessity issues. Challenging the qualifications of an individual performing a medical necessity review can pay off. The dismissal of the HCR ManorCare case drew attention because the government’s expert lied and failed to disclose notes, but…
November 16, 2017
By Ronald Hirsch, MD
Medical Necessity, IRF and DME: Three New Potential RAC Targets
CMS has posted three new issues the RACs have proposed for auditing, pending CMS evaluation and approval. Last week the Centers for Medicare & Medicaid Services (CMS) created a new page on its Recovery Audit Contractor (RAC) website titled Provider Resources. CMS indicated that it will post on this page…
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Allen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAmber Soucy, MSN, RNAndrew B. Wachler, Esq.Andrew B. Wachler, Esq. and Emma E. TrivaxAndrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler and Kaitlin NucciAndrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTAspen AlbrightBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBenjamin Kartchner MD, CHCQM-PhyAdvBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckClark AnthonyColleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RNDaniel Zirkman, MDDavid A. McKenzie, CAEDavid Jury MD, MSDavid M. Glaser, Esq.Delilah Davis, RN, BSN, CCADenise Coleman, LPNDenise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEllen Parucka Walker LCSW ACSWErica E. Remer, MD, FACEP, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, BSN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John K. Hall, MD, JD, MBA, FCLM, FRCPCJulia K. Brodt, PhDJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMadison AllenMaggie Elehwany, JDMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Anne Hayes Hartman, Esq.Mary Inman, Esq. and Max Voldman, Esq.Matt Lambert, MDMatthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael KennedyMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDSPhillip Angello, MDRalph Wuebker, MD, MBARichard “Dick” Beckley, YNS, USN, 1966-1970
