Monitor Mondays

There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits.  Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documenta...

An older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records. In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary f...

Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on...

Under siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey.  Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey res...

U.S. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health Committee, appears to be ready to shepherd his 165-page draft legislation on surprise balance billing for a vote next week.  In their push to get legislation prohibiting such billing through before the August recess, both the House and Senate have held hearings in the past two weeks on the various approaches to the problem. Those hear...

Most likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years.  But how can you and your team effectively deal with them? What tools and techniques are available?  During this edition of Monitor Mondays, John K. Hal...

Daniel Levinson, former head of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), will make his first broadcast appearance on Monitor Mondays since his announced retirement earlier this year. During his 15-year stint as the nation’s top healthcare watchdog, Levinson oversaw investigations into controversial health issues, including what was described as the la...

The fight is on, and combatants are sparring over how to implement a legislative ban on surprise balance billing.  In recent congressional testimony, providers, payers, and hospitals have clashed on how to keep patients from being stuck with huge expenses, with each side blaming the other for being intransigent. One of the major issues is how out-of-network doctors should be reimbursed, and at wha...

A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program.  U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association...

Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and...

The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid. More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have s...

News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing. Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albri...

New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA. Other segments to...

The Centers for Medicare & Medicaid Services (CMS) recently announced that 800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row (the HAC Reduction Program has only been in existence for five years).   The Code of Federal Regulations does not al...

The use and apparent abuse of observation and outpatient status are expected to have its day in court – again.  That’s because a federal judge has denied the government’s bid to put a stop to a landmark class-action lawsuit centering on patient status, paving the way for a trial expected to begin later this year. As reported by RACmonitor, in the court case Alexander v. Azar , the plaintiffs alleg...

In the final installment of a two-part series on prescription drug prices, during this edition of Monitor Mondays we will report on the latest initiative on a new “war on drugs” – the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered...

In the first portion of a two-part series on prescription drug prices, during this edition of Monitor Mondays we report on the Centers for Medicare & Medicaid Services (CMS) Drug Spending Dashboards with data for 2017. First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousand...

Could the Empire State be among the first to introduce a single-payer healthcare system? The latest news coming from Albany would seem to indicate that; now that both state legislative branches are under control of the Democrats, such an option is likely viable. Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no acces...

Pick up any healthcare news feed or relevant state or federal initiative, and no doubt you will see the "surprise billing" issue headlining. The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as "non-emergent."  Prudent acts amon...

The preponderance of ambiguously worded regulations from federal agencies – think the Centers for Medicare & Medicaid Services (CMS) – will be at the center of a major legal challenge coming March 26 to the nation’s highest court, and you’ll hear the details here during this edition of Monitor Mondays. That’s when Jennifer Gustafson will report our lead story, focusing on the U.S. Supreme Cour...

Reaction to the reporting here on forensic audits continues to reverberate. During last week's Monitor Mondays broadcast, Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc., reported on her experience and efforts to appeal what she describes as "spurious" denials. As reported last Monday, these denials are for commonly billed services and items such a...

Many hospitals are seeing increasing numbers of significant payment reductions that are the result of so-called “forensic” or other reviews conducted by third-party auditors. These are done on outlier claims, particularly for Medicaid HMO claims, as well as commercial and even Medicare Advantage claims. The denials are for commonly billed services and items such as supplies, IV solutions, point-of...

“It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place," President Donald Trump told members of Congress during his State of the Union address on Wednesday. "This is wrong, unfair, and together we will stop it. We will stop it fast," the President warned. During his address, the President also pl...

Are you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied?  Are you being told you cannot have a peer-to-peer session because your request was considered late?  Are you hearing that you must have everything — “pre-denial” or “pre-auth” — done within 72 hours of notificati...

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an updated memo on the subject on Thursday. The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story du...