Monitor Mondays

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...

“Are your CFOs agitated by the increase of outpatients in inpatient beds because of the removal of total knee arthroplasty (TKA), total hip arthroplasty (THA), and hundreds of other procedures from Medicare’s Inpatient-Only List (IPO) list?” asked Julie Collins recently on the RAC Relief listserv. “If the surgeon’s office is securing the prior authorization, how are they doing with securing the pr...

Changes to the nation’s Medicaid program, which reportedly covers some 70 million people, are expected soon. According to news reports, among the looming changes is the elimination of the work requirement for Medicaid recipients. This will mark the featured topic during the next live edition of Monitor Mondays, when healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will re...

After all this time, you could still be doing it wrong when it comes to Condition Code 44. If your hospital has been following the Medicare Condition Code 44 process associated with 42 CFR 482.30 because policy issued by the Medicare Advantage or commercial plans with which you’re contracted dictates its use, this may be the case, according to Dr. Juliet Ugarte Hopkins, the special guest during th...

With the purchase by UnitedHealthcare (UNC) of Change Healthcare, providers are contemplating notable differences between two sets of quidelines. Change Healthcare owns InterQual criteria, while UHC has traditionally used MCG criteria. Becoming familiar with the variances in terms of observation timeframes, screening methodologies, severity of illness thresholds, and intensity of service threshold...

To ensure compliance in conveying device credits and to identify providers who do not, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has a specific Annual Work Plan item to address the matter. Either through targeted device credit audits or enveloped in broader general billing compliance regulations for hospitals and ambulatory surgical centers (ASCs), th...

Billions of dollars in overpayments are levied annually against healthcare providers by the Centers for Medicare & Medicaid Services (CMS), based on the use of extrapolation audits. And while thousands of extrapolation audits are completed each year, the targeted provider or organization most likely will appeal the use of extrapolation. In nearly all cases, the appeal is focused on one or more...

Even as the nation continues to struggle with the coronavirus pandemic, President Joe Biden, who took office Thursday as the 46th President, signed executive orders mandating that masks be worn on federal property and for interstate travel on trains, transit systems, and airlines – this being part of the President’s agenda for the first 100 days in office. Meanwhile, shortages of the COVID-19 vacc...

Most physicians are expected to see in an increase in payments from Medicare, thanks to the latest COVID-19 relief bill. But with good news always comes some caution. First of all, the more that is paid, the more can be recouped during an audit. And with respect to provider compensation models that rely on relative value units (RVUs), it is possible that the increase in work RVUs may exceed the in...

With the calamitous year of 2020 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future of America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes expected to take place in 2021, you need to stay informed and alert – and RA...

Amid the chaos created by the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) released two major final rules this week: the 2021 Physician Fee Schedule and the Outpatient Prospective Payment System (OPPS), with the latter having been widely anticipated. Both final rules portend significant new regulatory changes for providers, patients, and payors. Given the gravity of...

A whistleblower recently exposed an alleged risk-adjustment scheme that was apparently designed to artificially inflate reimbursement provided under Medicare Part C, aka Medicare Advantage (MA). The accompanying lawsuit alleged that GHC hired an outside vendor to review and “improve” its risk adjustment scores. According to the whistleblower, GHC submitted t Reporting our lead story on this matter...

The next upcoming Monitor Mondays broadcast will encompass a special live open-door forum, coming at the intersection of compliance and the coronavirus – a jarring combination, in light of the fact that the continuing viral pandemic has claimed the lives of more than 250,000 and infected more than 11 million in the U.S. It is here, at this critical point, that providers are reconciling a patchwork...

There has recently been, as some might suggest, the luxury of taking a brief hiatus from medical record audits. But that was then, and this is now. Because now is the time to prepare, assess timeframes and provider requirements, and ensure that a proper compliance plan is in place. Certainly, audits are a growing source of concern, but there is no need for panic when adequately prepared, as you’ll...

The coronavirus winter surge is quickly approaching, and at a time when the United States is experiencing record numbers of daily positive COVID-19 tests, with corresponding increases in hospitalizations expected to follow. What the country needs now is for payers – both governmental and commercial – to reinstitute post-acute authorization waivers, since such waivers have largely expired. Currentl...