The biggest hurdle providers face is the prospective nature of the payment system. It was always a black hole. The Medicare Provider Reimbursement Review Board, or the PRRB, as it is commonly called, decided whether hundreds of Medicare cost report appeals would move forward or would be blocked for “jurisdictional…
EDITOR’S NOTE: CORRECTION:  In the RACmonitor Nov 29, 2019 edition, Dr. Ronald Hirsch noted that resource use data on skilled nursing facilities (SNFs) was not available on the SNF Compare website. Upon further investigation, the resource use data is, in fact, available indirectly from the SNF Compare home page. Subregulatory…
EDITOR’S NOTE: Healthcare attorney David Glaser reported on the CMS final rule’s reference to “shoppable” services during today’s edition of Monitor Monday. The following is his report. On Nov. 15, the Centers for Medicare & Medicaid Services (CMS) released an advanced copy of a final rule that will require all…
EDITOR’S NOTE: Virginia Gov. Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Sept. 25, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause.…
Addressing SDoH from an acute care perspective.  “Non-compliant:” please, remove this from your lexicon. It’s a pejorative doing injustice to patients and providers alike.  “Barriers to adherence to a prescribed regimen” is a better descriptor. The behavior has context. Patients very often have obstacles to optimal wellness, some self-inflicted, some…
There are resources available to help prevent wrongdoers from successfully targeting vulnerable patient populations. A dirty little secret of the long-term care industry is that the problem of identity theft arises more often than is reported.  In all fraud, there is the fraud triangle. The triangle sides are pressure, opportunity,…
The recent study was commissioned by the American Hospital Association and the Federation of American Hospitals. A report released last week found that the federal government has reduced Medicare and Medicaid payments to hospitals by nearly $253 billion, through 12 different legislative actions since 2010. $253 billion.   Two quick…
Physicians are sure to bristle at a perceived push toward non-physician practitioners operating more independently. EDITOR’S NOTE: President Donald Trump last Thursday signed an executive order tweaking the Medicare system during a campaign-style rally at The Villages, a Florida retirement community. In reporting on last week’s executive order signed by…
To understand the difference it is helpful to know the regulatory hierarchy. Last week’s article describing how Local Coverage Determinations (LCDs) are not binding prompted a question: what about National Coverage Determinations (NCDs)?  Are NCDs afforded more weight than LCDs? The answer is a resounding “yes.” NCDs are binding, but…
As a Medicare/Medicaid healthcare provider, you have a property right to your reimbursements for services rendered that were medically necessary. Why does it matter if your Medicare or Medicaid reimbursements constitute property rights? If you have a property right to something, it cannot be taken from you without due process…