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Utilization review (UR) activities have been around for decades. The scope of the activities run the gamut from a backward glance at physician documentation to ensure that the patient’s clinical picture and proposed interventions match the best-practice scenarios promoted by MCG and IQ, to real-time peer review by a team…
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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.…
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Maintaining records and accurately billing cannot be passed onto a third party like a billing company. Jamestown Regional Medical Center in Tennessee is in big trouble. Medicare and Medicaid were expected to cut off payments to the hospital Wednesday, with the agencies noting that the hospital currently does not meet…
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Federal entities are beginning to pay closer attention to hospitals’ financial wellness. Last week was Revenue Integrity Week, which marked an opportunity to acknowledge the work of the many people in health systems’ hospitals who help get a claim paid. I am always amazed that they can take our often-illegible…
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The promise of patients over paperwork may greatly benefit hospitals. The Centers for Medicare & Medicaid Services (CMS) has posted the 2019 Inpatient Prospective Payment (IPPS) Proposed Rule, with the agency suggesting it would strip away language that a physician’s order must be in the medical record in order for…
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The primary function of the hospital business office is to submit, process, and collect payment for healthcare claims. To complete these tasks effectively, millions of medical records are sent to third-party payers by business office personnel every year. These business office disclosures occur during the claims submission process or as…