March 14, 2019
Consideration of Consultation
Hiring a consultant can be a high-risk activity. Don’t get me wrong; I am definitely not disparaging consultants in general. A good consultant can get you out of a jam. I regularly rely on the wisdom of consultants, including my fellow RACmonitor authors and Monitor Mondays panelists, while assisting clients. But as…
February 7, 2019
CMS Audit Performance Gauged in HHS OIG Announcement
CMS squeaks by with B-plus in OIG audit. If the Centers for Medicare & Medicaid Services (CMS) received a grade for its audit performance during the 2015 and 2016 fiscal years, it would have been about a B-plus, maybe waived up to an A-minus, according to an announcement made recently…
January 24, 2019
OIG: CMS Did Not Always Resolve Audit Recommendations
CMS audit performance gauged in HHS OIG announcement. If the Centers for Medicare & Medicaid Services (CMS) received a grade for its audit performance during the 2015 and 2016 fiscal years, it would have been about a B-plus, maybe waived up to an A-minus, according to an announcement made this…
December 13, 2018
Actelion Pharmaceuticals Pays $360 Million to Settle Allegations of Kickbacks to Patients: Lessons Learned
Medicare patients were specifically excluded from the program. The U.S. Justice Department announced on Dec. 6 that Actelion Pharmaceuticals has agreed to pay $360 million to resolve allegations that it paid kickbacks by giving contributions to the Caring Voice Coalition, a charitable organization that then used the contributions to pay…
December 6, 2018
Suspicion Arises: All Errors, All the Time
100% error rate audits challenge credibility. Over the past five or six years, I have worked as a statistical expert on hundreds of extrapolation audits. And at least a couple dozen of these were based on 100 percent error rates. That means that the auditor determined that, of all of…
November 29, 2018
Medicare Disadvantage: The Down and Dirty of Capitation
OIG report cites widespread MAO problems related to denials of care and payment. Medicare and Medicaid are moving steadily into a capitated model system – or should I say, “have moved.” A central concern about the capitated payment model used in Medicare Advantage is the financial incentive for Medicare Advantage…
November 16, 2018
News Alert: OIG Poised to Conduct DRG Validation Audits
OIG discusses plans in 2018 Work Plan update The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced on Thursday that the agency, along with the Centers for Medicare & Medicaid Services (CMS), has noted “problems” with upcoding in hospital billing to increase payment. As…
October 11, 2018
Are Medicare Advantage Plans Creating Excessive Denials?
MAs are taking advantage of excessive denials to reduce payments to providers. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently found that between 2014 and 2016, a total of 75 percent of all appealed Medicare Advantage (MAs) denials were overturned, equivalent to roughly…
The UHC sepsis definition raises new audit concerns. Each month, UnitedHealthcare (UHC) keeps providers appraised about its policy changes with an online bulletin. These bulletins contain important information about pre-authorization requirements, changes to preferred providers, new fax numbers, and much more. In most cases, I read through it and find…
July 12, 2018
Malnutrition Billing Errors Trigger OIG Audit
Federal officials said the health system received overpayments of at least $2.4 million from 2014 through 2016. The University of Wisconsin Hospitals and Clinics Authority has found itself the target of an audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) for improperly…