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Best Practices for Responding to Individual Audits

There is no proven way for providers to avoid government audits for medical necessity. If a hospital is treating patients and submitting claims, at some point it will be audited. Given the increase in audits as the Centers for Medicare & Medicaid Services (CMS) contractor programs develop, a more appropriate name for a hospital's RAC rapid response team would be an audit rapid response team. When such a squad is Read more

Keeping Track of Your RAC Activity: Let Nothing Fall through the Cracks

In the same way that you wouldn't manage your patient flow without a sound registration system, you shouldn't manage your RAC program without RAC tracking software. Tracking software can help you keep up with medical record requests and appeal submissions, increase accountability as it pertains to due process and mitigate the risk of takebacks by helping your team ensure that everything possible is being done to reduce denials. There are Read more

Reading Between the Lines – Algorithms of Medical Necessity

EDITOR'S NOTE: This is the last article of a two-part series on the algorithms of medical necessity. As compliance professionals, the conversation about qualifying medical necessity or medical decision-making probably has surfaced at one time or another during education with providers, coders or auditors. As discussed in the first article of this two-part series, these phrases often are used interchangeably and have caused all of us to think about how to Read more

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

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May

2012

Officers and Directors Beware: The Government’s Focus on Individual Liability to Combat Healthcare Fraud

Written by Anna M. Grizzle and David S. Mitchell, Jr.

As evidenced by the unprecedented recovery of nearly $4.1 billion through healthcare fraud enforcement efforts in 2011, the federal government has made clear that cracking down on healthcare fraud is a top priority.¹ In 2011 alone, federal prosecutors filed criminal charges against 1,430 defendants for healthcare fraud-related crimes.² Furthermore, a total of 743 defendants were convicted of healthcare fraud crimes during the year.³ These record recoveries and prosecutions are the product of the government's use of a number of proactive measures, such as enhanced enrollment requirements, payment suspensions, and prepayment reviews, in its effort to combat healthcare fraud. Additionally, the government's increased use of private audit contractors has contributed to the increase in recoveries and prosecutions.

May

2012

Malnutrition: Documentation for Compliance and Clinical Accuracy

Written by Melinda Tully, MSN, CCDS

Is Code 260 now a government concern? Should you consider Code 260 a routine component of your clinical documentation improvement program?

A recent press release from a U.S. Department of Justice branch in Maryland announced an agreement through which Good Samaritan Hospital will pay nearly $800,000 to settle accusations of False Claims Act violations related to Code 260.

May

2012

OIG Studies Cites Evaluation and Management Vulnerability to Fraud and Abuse

Written by Chuck Buck

Medicare payments for Part B services and evaluation and management services both increased by more than 40 percent during the first decade of the new millennium, according to a study coordinated by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG).

Medicare payments for Part B goods increased by 43 percent, from $77 billion to $110 billion, from 2001 through 2010, the report indicated. Payments for evaluation and management (E/M) services spiked by 48 percent - from $22.7 billion to $33.5 billion - during that time.

May

2012

MACs: Unintended Consequences Order of the Day

Written by John Paul Spencer, CPC, CPC-H

As I previously related in a March 14 article on RACMonitor.com, on Jan. 3, 2012, the Centers for Medicare & Medicaid Services (CMS) shifted the responsibility of issuing Recovery Audit Contractor (RAC) demand letters from the RACs to the Medicare Administrative Carriers (MACs).

The reasons for this change were twofold. First, more than a year into the permanent RAC process, there remained discrepancies between the dollar amounts indicated on the RAC-generated demand letters and the amounts identified by the MAC as overpaid. The second and more subtle reason for the change was the belief that financial matters were better handled by one entity, rather than splitting them between the two.

Feature Stories

Why—and How—Should Hospitals Implement a CDI Program?

Janis Oppelt | Monday, 14 May 2012

We could not count on one hand the times that reports from Recovery Audit Contractors (RACs) have a guideline such as the following: Medical documentation for patients needs to be complete and support all services provided in the setting billed. Clearly, better documentation is essential to overpayment reductions, compliance,...

News Analysis

The Use of Observation in Patients Undergoing Outpatient Procedure

Steven J. Meyerson, M.D. | TUSEDAY, 17 January 2012

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...