Monitor Mondays

On Tuesday, the Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2. Dennis Jones, the administrator of pati...

2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. And RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade. Monitor Monday ho...

Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare & Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3. Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of car...

During this edition of Monitor Mondays, nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States dec...

Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem? Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the Americ...

U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. In other news, the Centers for Medicare & Me...

Long awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to the regulations governing evaluation and...

The Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November. The proposed changes are expected to impact compliance and reimbursement. Reporting this developing story during this edition of Monitor Mondays is author, educator, and consultant Duane Abbey, who will discuss how the proposed changes are likely to impa...

The Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program. Reporting this developing story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, who will discuss how the proposed changes are likely to impact Medicare providers. The broadcast rundown also will include: TPE: Targeted Probe and Educate...

Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referr...

UnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present.   If reviewers find no SOFA score in the medical record, that could spell trouble...

Home health providers are now on alert following an announcement on Wednesday that the Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas. In its announcement, CMS issued a notice for a 30-day public comment period. Reporting this developing story during this edition...

As expected, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.  T...

As bands of rain and wind from Hurricane Florence are lashing North Carolina, hospitals, health systems, and physician practices are preparing for what is being called the “storm of a lifetime.” Earlier this week, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that M...

Few proposals from the Centers for Medicare and Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E and M) reimbursement changes in the 2019 Medicare Physician Fee Schedule. The outrage has been intense over the plan to reimburse new patient visits at a single flat rate for codes 99202-99205 (...

A False Claims Act lawsuit has been filed by Integra Med Analytics against Providence St. Joseph Health, seeking $188.1 million related to alleged upcoding of Medicare claims. According to media reports, Integra made the discovery of allegedly unwarranted major complication and comorbidity secondary codes. In its investigation, Integra identified J.A. Thomas and Associates (JATA) as the clinical d...

“Podiatrists should not be discriminated against any further. E&M (evaluation and management) requirements are the same as (those for) other providers, and we should be reimbursed justly,” one podiatrist recently wrote, expressing his opposition to the Centers for Medicare & Medicaid Services’ (CMS’s) proposed E&M reimbursement changes in the recently posted 2019 Medicare Physician Fee...

The Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes in the recently posted 2019 Medicare Physician Fee Schedule continue to generate controversy. The controversy centers around the proposal by CMS to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, l...

The Medicare Physician Fee Schedule/resource-based relative value scale (MPFS/RBRVS) regulations were formally published in the Federal Register on July 27, 2018. The Outpatient Prospective Payment System/Ambulatory Payment Classifications (OPPS/APCs) was released two days prior. Both were reported by RACmonitor.  Although you can expect the final changes to published in early November, for a cont...

There’s a new and disturbing payer denial—a situation that has caught the attention of the Brundage Group. An insurance company removed the diagnosis of COPD exacerbation because the treating physician chose not to treat using steroids. Could this denial be happening at your facility? Dr. Brett Hoggard, chief medical officer for the Brundage Group, reports on this new and disheartening denial tech...

The 340B drug pricing program suffered a major setback Tuesday, when the U.S. Court of Appeals dismissed a key American Hospital Association (AHA) lawsuit to block $1.6 billion in cuts. The three-judge panel ruled that the lower court had properly dismissed AHA's case because the association failed to fulfill the legal prerequisites to judicial review. Reporting our lead story during this edi...

Case managers being situated in the emergency department (ED) appears to be a trend that is gaining traction nationwide, as results indicate that such a move helps determine appropriate status while also identifying patients who are appropriate for placement into a skilled nursing facility (SNF) directly (instead of placing them into the hospital while searching for a facility). We have two report...

The state of Kentucky has introduced Medicaid work requirements. And the trend seems to be proceeding fast and furiously in other states looking to cut health and behavioral health benefits of Medicaid enrollees, with officials saying the costs can’t be met otherwise. Kentucky eliminated vision and dental benefits to 500,000 Medicaid enrollees within 36 hours of the federal decision. Imagine the i...

The Office of Medicare Hearings and Appeals (OMHA) has implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process. The process provides appellants and the Centers for Medicare & Medicaid Services (CMS) an opportunity to discuss a mutually agreeable resolution for claims appealed to the administrative law judge (ALJ) or Medicare Appeals Council (Council) leve...

The National Institutes of Health (NIH)is expected to receive an additional $500 million to spend annually on pain management and opioid use. On Tuesday, the agency published details as to how the infusion of additional money will be used as part of a program titled “Helping to End Addiction Long Term (HEAL). " Earlier this week, the Centers for Medicare & Medicaid Services (CMS) approved...