Rules and regulations are always changing. Many readers may remember the Centers for Medicare & Medicaid Services (CMS) Transmittal 534. This was released in early August 2014, and it would have given Medicare contractors the ability to automatically deny associated physician claims when a hospital claim was denied. As written,…
There are winners and losers in the recently posted proposed rule. Weighing in at 1,824 pages, the Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year had something for everyone – and, in some cases, nothing at all. To the latter point, there’s no doubt that Ronald…
If approved, reviews would impact RAC Regions 1 through 4 in all states.In November 2017, the Centers for Medicare & Medicaid Services (CMS) announced that proposed Recovery Auditor (RAC) review topics would be posted. These topics, which have been proposed, but not yet approved, are available on the Medicare Provider…
CMS intends to target home health agencies in five states. It looks like the Centers for Medicare & Medicaid Services (CMS) is going to be targeting home health agencies in several states with another attempt to reduce fraud. Last week the agency announced that it is going to start another…
Improper use of extrapolation statistics is stunningly egregious, according to the author. Over the years, I have written extensively about the statistical extrapolations that are a large part of the audit process. In general, auditors—both government and private—make use of the extrapolation to significantly increase the overpayment estimates imposed on…
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,…
CMS has posted three new issues the RACs have proposed for auditing, pending CMS evaluation and approval. Last week the Centers for Medicare & Medicaid Services (CMS) created a new page on its Recovery Audit Contractor (RAC) website titled Provider Resources. CMS indicated that it will post on this page…
Should hospitals combine two admissions into one? In the absence of CMS guidance, hospitals are urged to do the right thing.  Last week I wrote a confessional for RACmonitor eNews, Hospital Admissions: Combining Two into One Doesn’t Add Up, about how I had been advising hospitals incorrectly on billing a…
The surprise is approval for RACs to audit admissions to inpatient psychiatric hospitals for medical necessity for inpatient psychiatric care. As we all know, all the Recovery Audit Contractors (RACs) are going full steam ahead with all their approved issues. And new issues are being added to the list on…
EDITOR’S NOTE: With Hurricane Irma expected to impact Miami-County today, this story, updated from a news alert posted last week on the ICD10monitor website, offers lessons learned for hospitals and caregivers in the path of Irma. Our thoughts continue to go out this week to the people of Texas, especially…
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