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Controversy Continues to Swirl Around Proposed E&M Changes

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, lower flat rate would apply to established patient visit codes 99212-99215. Code 99211 would also be paid...


2019 Medicare Physician Fee Schedule and the Outpatient Prospective Payment System: Analyzing the Impacts on Providers

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 contemporary analysis listen to Duane Abbey during this edition of Monitor Mondays. Duane Abbey is...


Beware: Emerging New Payer Denial for COPD

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 technique. The broadcast rundown also will include: The RAC Report: Hot Topics: Risky Business:...


Court Ruling Creates Major Setback for 340B Drug Program

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 edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner at the Potomac Law...


Case Management in the ED: Getting Patient Status Right the First Time

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 reports on this trending topic during this edition of Monitor Mondays. Leading our report is...


The Readmissions Quagmire: Medicaid Work Requirements Pose Audit Risks

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 impact to the readmissions quagmire if benefits continue to be cut for the most vulnerable...


Appeal Relief Has Arrived: OMHA Implements Expansion to Settlement Conference Facilitation

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) levels of appeal. Reporting our lead story during the next edition of Monitor Mondays will be...


Pain Points of Pain Management Services

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 facet joint injections for auditing, warning that auditors will review medical documentation to...


Total Knee Replacement: The Intersection of Functionality and Care Levels

The subject of total knee replacement (TKR) continues to reverberate. In this edition of Monitor Monday, Lori O’Hara, the lead of the ADR, appeals and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, will offer the perspective of a long-term care provider. Her position is that a TKR patient either needs medical oversight or they do not. The question of the proper environment, O’Hara answered by finding where the patient’s medical and...


Latest News: Feds Delay 340B Enforcement Rules

The Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally issued by the outgoing Obama Administration in January 2017. It was formally published on Monday. National Correspondent Timothy Powell reported our lead story on this episode of Monitor Mondays on 340B. The broadcast rundown also will...


IPPS Proposed Rule: Major Changes for IRF Providers

The dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear to be experiencing relief not typically associated with other proposed rule changes. For them, the proposals from CMS for FY 2019 reflect some positive changes related to reductions in paperwork and, if finalized, they will provide some...


Level of Care Versus Level of Care Billed: An Emerging Audit Problem

The problem begins like a blip on the radar screen: a curious anomaly that gradually grows more menacing. That is what Andrew Hughes, MD, and Charles Locke, both at Johns Hopkins, are noticing: an uptick in denials related to level of care provided versus the level of care billed. The majority of the denials arise when documentation indicates that a patient is "stable for downgrade" and a transfer has been initiated but not yet effectuated due to a lack of an available bed, reported Dr....


Auditing Non-physician Practitioners

Could non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors? While physicians reportedly represent nearly a million targets for audits, add in another couple of hundred thousand nurse practitioners (NPs) and physician assistants (PAs) and target acquisition becomes that much richer. And in their minds, so do the auditors, according to Frank Cohen, director of analytics and business intelligence for...


Facebook: Healthcare’s Social Media Menace

Facebook CEO Mark Zuckerberg faced two days of grilling by Congress last week to address data misuse in the wake of revelations that millions of Facebook users had their private information given away to political consulting firm Cambridge Analytica in the run-up to the 2016 Presidential election. Zuckerberg testified before Congress that about 87 million users had their Facebook data taken without their permission. Of those users, many were healthcare professionals who inadvertently...


AHA Ordered to Fix the Medicare Appeal Backlog

Judge James E. Boasberg of the United States District Court for the District of Columbia has ordered the American Hospital Association (AHA) to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the Administrative Law Judge (ALJ) level. Reporting this developing story is healthcare attorney Andrew Wachler, Esq., managing partner at Wachler and Associates. The episode rundown also includes: Monday Rounds: Hot Topics: Risky Business: Consumer...


Medicare and Medicaid RAC Audits: How Auditors Get It Wrong

RACmonitor was founded in 2008 to provide news and information for healthcare providers on the emergence of the government’s Recovery Audit Contractor (RAC) program. From a Centers for Medicare & Medicaid Services (CMS) demonstration in that year, and continuing to the national rollout in 2010 (coincidentally, the year of Monitor Mondays’ national debut), we have been reporting on activities not only of the RACs, but also the Medicare Administrative Contractors (MACs), Zone Program...


Quelling the Confusion Over Modifier 25

"Anthem Blue Cross Blue Shield (BCBS) was set to implement a new processing edit with regard to the use of Modifier 25, effective March 1, 2018, but things didn't go as planned," reports Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS), as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. During this episode DeConda explains why Anthem is rescinding the new policy. The episode rundown also...


Time to Junk the Peer-to-Peer Process?

"The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians," reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. "These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient." During this episode of Monitor...


Total Knee or Total Consternation?

Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility? Mary Beth Pace, vice president of care management at Trinity Health and the special guest on this edition of Monitor Mondays, frames the conundrum as a hypothetical patient/caregiver conversation: "we are going to do major surgery...


EMR and RAC Audits: Who Takes the Hit? Part II

Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor Mondays, when whistleblower attorney Mary Inman reports on an ongoing qui tam action under the federal False Claims Act through which a relator alleges that Bon Secours Health System, Inc. fraudulently billed Medicare and Medicaid millions...