Part II continues to explain the nuances in the changes made by CMS to its statistical sampling methodology. The Centers for Medicare & Medicaid Services (CMS) recently made significant changes in its statistical sampling methodology for overpayment estimation. Effective Jan. 2, 2019, CMS radically changed its guidance on the use…
Effective Jan. 2, 2019, the Centers for Medicare & Medicaid Services (CMS) radically changed its guidance on the use of extrapolation in audits by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SMRC). Extrapolation is a veritable tsunami in…
The ADR rule went into effect Jan. 1, 2019 The Centers for Medicare & Medicaid Services (CMS) has updated its criteria for additional development requests (ADRs). If your ADR “cycle” is less than 1, CMS will round it up to 1. When a claim is selected for medical review, a…
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…
New case law supports due process for Medicare providers. Due process is one of the cornerstones of our society. Due process is the universal guarantee and found in the Fifth Amendment to the United States Constitution, which provides "No person shall…be deprived of life, liberty, or property, without due process…
New RAC targets are being proposed by CMS as the agency seeks to consolidate Medicare audits. You have to stay on your toes when you deal with Recovery Audit Contractors (RAC) audits— not to mention all the other types of regulatory audits that health care providers undergo. This article investigates…
Pending a possible government shut down, this bill would allow documentation from a home health agency to be considered when records are reviewed.  Late on Feb. 5, the U.S. House of Representatives introduced a “bipartisan” bill to avoid another government shutdown. While the big healthcare news of this bill was…
A False Claims Act case pits a prominent health system against its EHR software provider. Over the last many years, healthcare providers have been financially incentivized to purchase electronic health records (EHR) software. These programs can cost upwards of $25,000 to $50,000, and, sometimes are renewable every year. In other…
The guy either has no idea how the process works or he has mastered the art of lying with statistics. In May 2014, the American Hospital Association (AHA) sued the Secretary of Health and Human Services (HHS) in an attempt to force the government to do something about the ridiculous…
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…
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