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…
Medicare has not been paying its fair share of medical costs for decades. Medicare for all: what would it do to hospitals? Hospital CFOs tell us that Medicare does not pay as much as other payers, and that Medicare for all would result in many hospitals closing. To answer this…
Although the details of federally ordered auditing of providers have changed over the years, one thing remains the same. We have lived for years under the Sword of Damocles – the continuing waves of healthcare audits by federal contractors. The names of the Medicare Recovery Audit Contractors (RACs) have changed…
Balancing patient advocacy with access to Part A Medicare skilled nursing benefit. The ambiguities of Medicare regulations often create conundrums for case managers and physician advisors as we try to advocate for our patients while remaining compliant. One area that often creates a dilemma in balancing patient advocacy with compliance…
CMS also has updated its therapy manuals, making elimination of FLR official. Many therapy providers, at hospital outpatient departments and private-practice clinics alike, were reluctant to stop submitting functional limitation reporting codes and impairment modifiers until they could see the guidance clearly written in black and white in the associated…