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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…
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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…
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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…
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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…
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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…
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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…
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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…
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CMS offers advice through its Medicare Learning Network Connects bulletin to avoid coding errors. Mistakes happen, and errors do occur in the coding industry. The May 24 Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network (MLN) Connects bulletin included provider compliance information that is noteworthy and important to…
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Recoupment and one-day inpatient admission for total knee replacement. EDITOR’S NOTE: The following is a summary of a broadcast segment on Monitor Monday, May 7 by the author. While we are still trying to make sense of what the Centers for Medicare & Medicaid Services (CMS) meant with its proposal…
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OIG audits device credit reporting. The confluence of two major healthcare news stories is creating confusion among providers. News of changes to the national coverage determination (NCD 20.4) for implantable cardioverter defibrillators, as first reported by Ronald Hirsch, MD, for RACmonitor, nearly collided with a report on device credit from…