Frank D. Cohen, MPA, MBB | March 20, 2014

Guilty Until Proven Innocent

A few years ago, I accepted an engagement with a physician practice that had undergone a Centers for Medicare & Medicaid (CMS) audit – and, as a result of the extrapolation, was required to repay over a million dollars in what the auditor labeled overpayments. My job was to conduct a full statistical review of the sampling, point estimates, and extrapolation and render an opinion as to the validity of …

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David M. Glaser, Esq. | March 20, 2014

Ding Dong, the RACs are Dead? Don’t Get Your Ho

The Centers for Medicare & Medicaid Services (CMS) has announced that as it enters the procurement process for the next round of RAC contracts, it is instructing the current RACs to pause their work. The announcement, which appeared on the CMS website at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html, indicates that RACs were to stop sending post-payment audit requests on Feb. 21, 2013 (note that the instruction indicates that this was the last date the request could …

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Ronald Hirsch, MD | March 20, 2014

Did CMS Nearly Eliminate Condition Code 44?

Sept. 10, 2004 was a landmark day for hospitals. That was the day that the Centers for Medicare & Medicaid Services (CMS) issued Change Request 3444 and MLN Matters SE0622, establishing guidelines for the use of Condition Code 44 to change a hospitalized patient’s status from inpatient to outpatient when it was determined that there was no medical necessity for an inpatient admission. The Condition Code 44 process required involvement …

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03.25.2014
Drill Down: Polysomnography Reported with Incorrect Diagnosis
Drill Down: Polysomnography Reported with Incorrect Diagnosis

RAC Region B contractor CGI posted an automated review issue that was approved on March 6, 2014, for Outpatient providers targeting overpayments for polysomnography procedures when reported with the incorrect diagnosis. Per the contractor’s description of this audit issue, polysomnography, the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of...

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03.20.2014
CMS Changes Its Mind on Denial of Related Claims
CMS Changes Its Mind on Denial of Related Claims

Aside from recoupment of the surgeon’s fee for denied joint replacement admissions by First Coast Service Options in Florida, physicians have in the past been financially held harmless for their decisions to admit a patient to the hospital or perform a procedure on their patient. But that was about to change when, on February 5, 2014, CMS released Transmittal 505. In...

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03.18.2014
Drill Down: Excessive Units of Hospital Visits
Drill Down: Excessive Units of Hospital Visits

RAC Region B CGI posted an automated review issue that was approved on Feb. 2, 2014 for providers regarding initial hospital procedure codes 99221-99223 and Subsequent procedure codes (99231-99233) which are considered “per diem” codes and cannot be used by the same specialty providers from the same group practice. The issue references retired Local Coverage Article:  Initial Hospital Care Visits – Medical Policy...

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03.06.2014
OIG Cites Performance Issues with CMS and Contractors
OIG Cites Performance Issues with CMS and Contractors

Noting that the Centers for Medicare & Medicaid Services (CMS) contractors are responsible for administering more than half a trillion dollars in Medicare benefits annually, the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG’s) Robert A. Vito said Tuesday that the OIG has discovered a number of “recurring issues” that limit CMS’s oversight across all...

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OIG

OIG Releases “Robust” Work Plan to Tackl…

Janis Oppelt | 02.06.2014

OIG Releases “Robust” Work Plan to Tackle New Healthcare Market Place

Millions of people who were previously uninsured will gain health insurance coverage in 2014, thanks to the Patient Protection and Affordable Care Act (ACA) of 2010. The ACA, which enacted...

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Feature Articles

Providers Weigh in on ALJ Appeal Delay

Chuck Buck | 01.23.2014

Providers Weigh in on ALJ Appeal Delay

Providers were quick to react to the decision by the Office of Medicare Hearings and Appeals (OMHA) to suspend new hearing requests for two years. In an OMHA memo obtained by...

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IRF

Inpatient Rehabilitation Facilities: Wha…

Angela Phillips, PT - avatar Angela Phillips, PT | 02.20.2014

Inpatient Rehabilitation Facilities: What Are We Seeing in Audits?

In a follow-up to our series of articles on the technical requirements of the January 2010 updates to the regulations for inpatient rehabilitation facilities (IRFs), in this article we are...

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