Refund only after careful thought. The risk of rushing to refund: not only is it alliterative, it is real. The proper desire to be compliant can prompt a hasty decision to return money to the government. While it is both wise and necessary to return overpayments to Medicare and Medicaid,…
Medicare Advantage plans appear to be following their own rules. Many of the national Medicare Advantage (MA) plans are misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care provided to their members. That was the assessment…
We have been reminding inpatient rehabilitation facilities (IRFs), repeatedly of late, and now we’re down to the final two months before the transition away from utilizing Functional Independence Measures (FIMtm) to assign patients to a case-mix group (CMG) and toward using key quality indictor data – specifically, the GG Self-Care…
Rules and regulations are always changing. Many readers may remember the Centers for Medicare & Medicaid Services (CMS) Transmittal 534. This was released in early August 2014, and it would have given Medicare contractors the ability to automatically deny associated physician claims when a hospital claim was denied. As written,…
A new five-year partnership between the Boston University School of Public Health and Sharecare is launched. Over the past decade, there has been a data explosion in healthcare, especially for tracking, defining, and addressing the social determinants of health (SDoH). This has included the following: Predictive analytics to prioritize Medicaid…
Coverage would include those suffering from chronic lower back pain who are also enrolled in approved studies. The Centers for Medicare & Medicaid Services (CMS) is proposing to cover acupuncture for Medicare patients who suffer from chronic lower back pain and are also enrolled participants in certain clinical trials –…
Two nearby rural facilities with the same owner remain open amid the crisis. A troubled rural Tennessee hospital has been forced to close. As reported by RACmonitor Thursday, local reports today indicate that Jamestown Regional Medical Center in northern Tennessee had its doors locked as of Thursday evening, with a…
Let’s talk targeted probe-and-educate (TPE) audits – again. I received quite a bit of feedback on my recent RACmonitor article regarding Medicare TPE audits being a “wolf in sheep’s clothing.” So I decided to delve into more depth by contacting providers who had reached out to me to discuss specific…
Let’s talk targeted probe-and-educate (TPE) audits. TPE audits have turned out to be “wolf audits” in sheep’s clothing. The Centers for Medicare & Medicaid Services (CMS) asserted that the intent of TPE audits is to reduce provider burden and appeals by combining medical review with provider education. But the “education”…
A complex process is simplified in a tabular comparison. Not infrequently, in the process of utilization review (UR), we run into situations in which, as physician advisors, we get to review Medicare cases that do not match their original “label” (i.e. the initial status selection was likely not a proper…