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Out-of-Network Reimbursement: Don’t Expect Insurers to Do the Right Thing

Former New York Attorney General and current Gov. Andrew Cuomo early in 2008 conducted an investigation into what he viewed as under-reimbursement of out-of-network claims by most insurers in the state. Cuomo investigated what he referred to as "industry-wide" usual, customary and reasonable (UCR) underpayments that affected consumers in New York and nationwide. He described this as a scheme by certain Read more

Predictive Modeling: A Silver Lining in the Perfect Storm

As the provisions of the Patient Protection and Affordable Care Act begin to go into effect, the healthcare industry is headed toward what many consider to be the perfect healthcare storm. Providers, and physicians in particular, are facing uncertainty with respect to what they can expect in terms of reimbursement for the care they provide and even the way they Read more

The Use of Observation in Patients Undergoing Outpatient Procedure

The outpatient observation generally is ordered when physicians require time to complete the evaluation of an ED patient to determine the need for admission - or to complete simple treatment that can be rendered within in 24 hours - but it also may be ordered following outpatient surgery when the normal recovery period has to be extended for the management Read more

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This Week's Top Stories are sponsored by: Panacea Healthcare Solutions, LLC.

Jan

2012

RAC Region A Posts Issues by Major Diagnostic Category

Written by Karen Long

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DCS Healthcare has changed how it posts issues from listing individual MS-DRGs to major diagnostic categories (MDCs).

Providers should note that each category includes several MS-DRGs that the Region A recovery auditor (RAC) will review. For example, MDC 5 (diseases and disorders of the circulatory system) lists eight MS-DRGs, including MS-DRG 239 (amputation for circulatory system disorders except upper limb and toe with major complications and comorbidities) and MS-DRG 298 (cardiac arrest, unexplained without complications and comorbidities or major complications and comorbidities).

Jan

2012

CMS Updates its Electronic Submission of Medical Documentation

Written by Melanie Combs-Dyer, RN

Healthcare providers who receive documentation request letters from Medicare Review Contractors can now respond electronically. Until now, providers had only twp options: mail or fax. The Centers for Medicare & Medicaid Services (CMS) calls the new mechanism Electronic Submission of Medical Documentation, or esMD.

Jan

2012

RACTrac Survey Reveals More Realities of Hospital Audits

Written by Kim T. Charland, BA, RHIT, CCS

Most of the medical-necessity denials uncovered by complex reviews conducted by recovery audit contractors (RACs) come down to one-day stays in medical/surgical acute-care hospitals. The interesting thing about this is that the denials occurred because the service provided was provided in the wrong setting. RACs collected $89 million of overpayments from the group of hospitals that reported this piece of data to the American Hospital Association (AHA) for its latest RACTrac Survey (November 21, 2011 report).

Jan

2012

More Providers Budgeting for RAC Recoupments

Written by Chuck Buck

Heeding songwriter Steven Bishop's old refrain, "you better save it for a rainy day," 52 percent of respondents to an online survey reported that they are budgeting for a reserve fund based upon past RAC experiences.

The survey was conducted Monday during Monitor Monday, a weekly podcast produced by RACmonitor. Behind that group were the 20 percent of respondents who stated that they were budgeting for their reserve fund based on published industry standards. Interestingly, 25 percent responded with the answer "fingers crossed or no reserves or insurance." To the latter point, 1 percent had purchased RAC-specific insurance, while another 2 percent responded that they had an add-on to reinsurance or had a stop-loss policy.

Feature Stories

RACs Fall Short in Third Quarter by $82.5 Million

Vickie Axsom-Brown | Wednesday, 3 August 2011

EDITOR’S NOTE: This is the first in a two-part series by former RAC Region D vice president Vickie Axsom-Brown.The CMS news of Recovery Audit Contractor (RAC) returns through the third quarter of the 2011 fiscal year has gained much attention. CMS’s goal for 2011 is to accomplish what the RAC...

40 Providers Referred to OIG by RACs

Mark Spivey, Contributing Writer | Wednesday, 3 August 2011

WASHINGTON, D.C. – The U.S. Department of Health and Human Services (HHS) Office of Inspector General has launched more than 1,700 healthcare fraud investigations since the start of the current fiscal year, according to eye-opening Congressional testimony delivered last week by HHS Inspector General Daniel R. Levinson. That figure is...

News Analysis

Top Reason for RAC Denials: Lack of Medical Necessity in Wrong Setting

Carol Spencer, BA, RHIA, CCS, CHDA | Wednesday, 1 June 2011

The American Hospital Association (AHA) continues to collect and report valuable data from its web-based RACTrac survey. As summarized below, its May 20, 2011, report includes new findings from the first quarter of 2011, including the fact that lack of medical necessity is the top reason for claim denials...