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…
The search for a solution might begin with CMS. We have a problem in America. We spend way too much money on healthcare, and the outcomes we do get are not great. I am pretty darn tired of hearing about the move from volume to value. Do you know what…
CMS cited by GAO for insufficient documentation. The Government Accountability Office (GAO) issued a report on March 27 stating that the Centers for Medicare & Medicaid Services (CMS) should assess documentation necessary to identify improper payments. The study was performed on Medicare and Medicaid fee-for-service (FFS) improper payment data for…
Major takedown by DOJ sends shivers through skilled nursing facilities. Philip Esformes, the operator of 16 skilled nursing and assisted living facilities in South Florida, was found guilty Friday of 20 charges, including paying bribes and kickbacks to bring Medicare patients into his businesses. According to Assistant Attorney General Brian…
AI tools include anomaly detection, predictive analysis, and social network analysis. Medicare fraud is a serious issue and an expensive one. “Improper payments” amount to more than $52 billion per year. Our government uses subcontractors to do its work. They have corrected around $500 million (half a billion dollars) in…
Hospitals may consider abandoning their contracts. There are few things managed Medicare plans have come up with that are more unfair to hospitals than denials due to readmission. Hospitals with contracts with managed Medicare payers often must endure these denials, as they are not often excluded in contracts. Managed Medicare…
New CMS pharmacy dashboards include data sets from 2013 to 2017. The Centers for Medicare & Medicaid Services (CMS) has released its latest “CMS Drug Spending Dashboards.” While the dashboards are interactive (you can look up specific drug data), we took a broader approach and downloaded and analyzed the source…