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…
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…
All audits are questionable, contends the author, so appeal all audit results. Providers ask me all the time – how will you legally prove that an alleged overpayment is erroneous? When I explain some examples of mistakes that Recovery Audit Contractors (RACs) and other health care auditors make, they ask,…
OIG report shines spotlight on area of confusion for billing. In a recent report, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced it has determined that Medicare inappropriately paid acute-care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities.…
The OIG has added specialty drug coverage and reimbursement by Medicaid to its Work Plan.  In October, the OIG added specialty drug coverage and reimbursement by Medicaid to the list of active Work Plan items. This was in addition to the continuing Medicaid-related prescription drug reviews for the 2017 fiscal…
Tales abound regarding contractors’ errors negatively impacting providers.  If you read my previous article on the audit by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) on billing of services by acute-care hospitals that were provided to patients who were inpatients at another facility,…
The resignation of HHS Secretary Tom Price, MD casts doubt on initiatives championed by the former orthopedic surgeon in altering the trajectory of the Patient Protection and Affordable Care Act. Under intense criticism and amid growing frustration by President Donald Trump, U.S. Department of Health and Human Services (HHS) Secretary…
Once a year, for the past eight years, the U.S. Attorney General has announced his or her annual healthcare fraud enforcement efforts in the form of the U.S. Department of Justice’s (DOJ) “National Health Care Fraud Takedown.”  The Takedown, which compiles the year’s healthcare fraud-enforcement actions, is a reflection of…
More than 400 people across the country have been charged in connection with $1.3 billion in healthcare fraud losses as part of what the federal government has labeled the largest enforcement action of its kind in U.S. Department of Justice (DOJ) history. United States Attorney General Jeff Sessions and U.S.…
EDITOR'S NOTE: Edward Roche, in association with RACmonitor, is writing a series on the need for U.S. healthcare facilities to protect themselves from cybercriminals demanding ransoms for patient records. This is the sixth installment in this series. Cybersecurity audits now are becoming an integral part of the internal control requirements…
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