A Backlog of Appeals Prompts the Question: Should CMS Stop the Audits?

“Because of a very heavy and ever-expanding caseload of appeals arriving in our office, we do not anticipate scheduling this case for hearing and decision until the last quarter of FY 2014. Many of the cases that we are receiving will not be heard and decided until the first and second quarters of FY 2015.”

That’s what one administrative law judge (ALJ) from the Department of Health and Human Services’ Office of Hearing and Appeals wrote in a recent letter to one Mid-Atlantic health system.

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CMS Proposes Using a Time-Based Presumption To Review Inpatient Admissions

The Centers for Medicare & Medicaid Services (CMS) has proposed a significant revision to the definition of “inpatient” in an attempt to clarify its policy on how Medicare contractors review inpatient admissions for payment purposes.

The proposed revision, included as part of the agency’s proposed inpatient prospective payment system (IPPS) rule for the 2014 fiscal year, uses a time-based presumption that raises a number of questions.

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Compliance and ‘Key Performance Indicators’

Laventhol and Horwath (L&H) was the seventh-largest public accounting firm in the United States when it failed in November 1990. Many of us old-timers in healthcare fondly remember L&H for creating one of the first computerized Medicare cost reports. I am old enough to remember doing cost reports with a pencil and calculator.

L&H did not go bankrupt because it was doing something other firms were not doing. L&H went bankrupt because it could not afford the settlements from the lawsuits that are filed against accounting firms every day. Frankly, they ran out of money.

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Preadmission Assessment Screening for the Inpatient Rehabilitation Facility: What Medicare Requires

As we outlined in our previous article, RAC audits are focusing not only on the clinical issues that support reasonable and necessary care, but on the ability of inpatient rehabilitation facilities (IRFs) to meet the technical requirements of the rules and regulations that were updated effective Jan. 1, 2010. This article will outline the requirements for the preadmission assessment screening (PAS) process and identify potential pitfalls for IRFs in their attempts to meet those requirements.

While Medicare historically has required that IRFs implement a preadmission assessment process, the aforementioned regulatory changes outlined very specific requirements. Failure to meet the specific time and content requirements can result in denial of payment for services provided to Medicare beneficiaries.

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