Monitor Mondays

“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...

The United States Department of the Treasury’s Office of Foreign Assets Control (OFAC) recently issued an advisory on potential sanction risks for facilitating ransomware payments. It warned that entities, including hospitals, paying off ransomware demands might be subject to civil monetary penalties under the International Emergency Economic Powers Act (IEEPA). This action places hospitals in dan...

Providers that received payments from the federal Provider Relief Fund will be required to file reports demonstrating their compliance with the terms and conditions of those payments. Reporting on this, our lead story during the next live edition of Monitor Mondays, will be healthcare attorney Andrew Wachler, managing partner of Wachler & Associates. Mr. Wachler will report on anticipated “hot...

More payment cuts are being proposed by the Centers for Medicare & Medicaid Services (CMS) for next year, a move sure to impact the many hospitals participating in the 340B drug discount program, as described in the 2021 Medicare Outpatient Prospective Payment System (OPPS) Proposed Rule. Such proposed cuts are expected to reduce Medicare Part B drug payments to levels lower than in 2018, when...

The venerable topic of length of stay (LOS) has recently been generating buzz among healthcare professionals – so much so that we asked Stefani Daniels, founder and managing partner of Phoenix Management, to return to the weekly Monitor Mondays broadcast with an update, noting that the use of LOS has apparently declined. But is it still a valuable metric? And how might LOS be used today? This ques...

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently closed in on more than 345 defendants charged with participating in scams involving more than $6 billion in alleged losses to federal healthcare programs. The takedown occurred in September, according to the OIG. Of that amount, approximately $4.5 billion was associated with telemedicine schemes. The...

The Centers for Medicare & Medicaid Services (CMS) has moved to stop Medicare Advantage Organization (MAO)-hired subcontractors from issuing “pseudo-denials” that require pseudo-appeals before the MAO considers the denial formalized. The practice is reported to be extremely widespread and used against non-contracted providers: small, often rural hospitals that tend to be more vulnerable to the...

The recent announcement by the Centers for Medicare & Medicaid Services (CMS)  that it will be “ramping up” audits are quickly becoming a reality for providers across the country. Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), and Unified Program Integrity Contractor (UPIC) auditors are going full steam ahead, using data and...

The Centers for Medicare & Medicaid Services (CMS) will reimburse a greater number of relative value units (RVUs) associated with office-based evaluation and management (E&M) visits, the agency announced recently. In order to achieve budget neutrality, CMS will reduce the payment per RVU. With this change, CMS is allocating a larger proportion of its total spending to office-based physicia...

Unlike the Cold War arms race between the then-Soviet Union and the United States, today’s arms race is being fought before computer monitors, and in the deep corners of computer laboratories. And the weapon of choice: algorithms. This fierce fighting is taking place between auditors and providers, and the stakes are high: money. Lots of it. No stranger to chronicling the former Cold War arms race...

In recent weeks, several major pharmaceutical manufacturers have taken actions that could lead to narrowing the 340B Drug Pricing Program, which provides outpatient drugs to safety-net hospitals, health centers, and clinics at discount prices. The savings are invested in care for patients with low incomes, living in rural communities. The actions by Eli Lilly, Merck, and Sanofi are being challenge...

California is one of two states in the country that rewards whistleblowers for bringing forward information about private insurance fraud. A recent $24 million settlement with pharmaceutical giant Abbvie over the marketing of the company’s blockbuster drug, Humira, demonstrates the law’s effectiveness. The settlement agreement was reached last week following allegations that the company violated C...