Monitor Mondays

Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not present. Reporting on these all-too-common and unwel...

They take no breaks. Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trusted weekly news and information Internet radio broa...

2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior.  The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and does it change the potential for audit risk?  J...

In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims. The decision is likely to have serious ramifications, to the tune of tens of billions of dollars. It’s been estimate...

The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits. Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the low-hanging fruit created when administrators, phys...

Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries. Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn the extent of recent auditing activities, listen to...

Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight.  Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation.  Adding insult to injury is a new ruling handed down by the 5th Circuit Court al...

The COVID-19 pandemic might have subsided somewhat, but in the eyes of the Centers for Medicare & Medicaid Services (CMS), it is anything but over, as the agency continues to treat providers as if it were still surging. In order of priorities, CMS is starting to push Targeted Probe-and-Educate (TPE) audits, according to healthcare attorney Andrew Wachler. He reports that his firm is starting t...

SPECIAL GUEST Edward Roche, JD, PhD Director, Scientific Intelligence, Barraclough NY LLC ALSO FEATURING Matthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP; David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQ RACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant abuse directed at healthcare providers by overzea...

Six major U.S. drug manufacturers are refusing to provide 340B discount pricing for outpatient drugs sold to safety-net hospitals, community health centers, and public health clinics when those drugs are dispensed in community pharmacies. Will it take an act of Congress to intervene in this ongoing battle to restore 340B discounts and refund overcharges? Maureen Testoni, J.D., President and CEO of...

If your facility is considering submitting an amended claim request for a higher-weighted diagnosis-related group (HWDRG), be aware: the Centers for Medicare & Medicaid Services (CMS) has the authority to have your amended claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). And that alone could open up Pandora’s Box. Reporting our lead story du...

There are lists upon lists of hospital rankings. But there’s one list you’ll certaintly want your hospital to avoid. A report from Johns Hopkins University has revealed that many of America’s top 100 hospitals are using predatory tactics to pursue lawsuits against patients. Highlighting this list are government hospitals as well as nonprofit health systems called out for hounding patients to colle...

UnitedHealthcare is the latest insurer to join the growing lineup of payors that want to second-guess patients and deny payment for emergency department (ED) services after they’ve been rendered. As reported here on Monitor Mondays last week, UnitedHealthcare plans to extend no coverage or limited coverage to ED claims, retroactively – including any claims the giant insurer deems non-emergent. Our...

Are your physicians providing detailed documentation as they adhere the 2021 Evaluation and Management (E&M) Guidelines? Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement, is concerned that they might not be – which, he believes, squarely puts them in an uphill battle, defending themselves from quality audits and potential malpractice suits. And...

There was a time when the word “logjam” seemed to be synonymous with the Administrative Law Judge (ALJ) hearings conducted under the purview of the Office of Medicare Hearings and Appeals (OMHA). Today, by all accounts, hearings are being scheduled almost back-to-back, and attorneys are scrambling to represent their clients during unprecendented times. Preparing for a multi-million-dollar hearing...

“Incoming!” are the typical dreaded shouts heard from soliders hunkered down in bunkers when shelling begins. Today, across America, you can hear the same cries when it comes to claims auditing. Audits are incoming. Third-party auditors, governmental auditors, even auditors from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) looking at COVID-related claims...

Several hospitals have now received audit notices from the HHS Office of Inspector General (OIG) for COVID-related claims. The OIG has begun auditing hospitals to “determine whether Medicare paid hospitals for these inpatient claims in accordance with federal requirements.” Make no mistake, the OIG is auditing provider billing, not payment. The OIG is not auditing Medicare Administrative Contracto...

What percentage of administrative law judge (ALJ) decisions end up at the Medicare Appeals Council? What percentage of those decisions are reversed? These are important questions asked by a reader in response to a recent article written for RACmonitor by Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement. Cohen, who has extensive experience as a subj...

They’re using text messages. They’re offering vaccination cards, and even COVID-19 testing. They’re scammers. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is currently warning that providers that charge impermissible fees must refund them, and ensure that individuals are not charged any sum at all, for the COVID-19 vaccine – along with warning of fraudul...

With little in the way of reporting on the backlog of appeals at the Administrative Law Judge (ALJ) level, you could conclude that such hearings are on hiatus. But that’s not the case, according to senior healthcare consultant Frank Cohen, who will be reporting the lead story during the next live edition of Monitor Mondays. Cohen, director of business intelligence at DoctorsManagement, is expected...

President Joe Biden’s roughly $2 trillion infrastructure proposal, called the “American Job Plan,” includes approximately $400 billion to expand access to home care and community-based services, including access to long-term care provided under Medicaid. Reporting on the impact of this possible new fusion of funding during the next edition of Monitor Mondays will be William Dombi, president of the...

The initiative to vaccinate enough Americans to achieve herd immunity against the deadly coronavirus appears to be stalling – this in the face of increases in infection rates. According to data from the Centers for Disease Control and Prevention (CDC), the country has experienced an average of 65,000 new cases in the last seven days. Reporting our lead story during the next edition of Monitor Mond...

“Ridiculous denials are frustrating. Vent, and then respond,” Dr. Andrew Markiewitz advises. “But ask: are you arguing over the Titanic’s deck chairs?”   “Insurers may correctly identify unsubstantiated diagnoses,” Markiewitz added – and, if their findings are legitimate, return the money. If the DRG or reimbursement doesn’t materially change, after all, where’s the value? Fighting the fight worth...

Healthcare data breaches and the possibility of sanctions from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) are a rightfully terrifying possibility for healthcare administrators. But one hospital, MD Anderson Cancer Center, recently fought back and won. Reporting on the outcome of the decision handed down by the 5th Circuit Court of Appeals during the next l...

Now that the auditing reset button has been pressed, you and other providers can expect a torrent of audits and recoupments. In this new aggressive auditing environment, propelled by commercial as well as governmental auditors, providers must continually update their approach in response. Against this chaotic background, there’s a new legal approach to audit defense advocated by Wachler & Asso...