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Targeted Probe-and-Educate Audits: Three Strikes and You’re Out

Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC),...


UnitedHealthcare Puts Sepsis in the Crosshairs

UnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present. If reviewers find no SOFA score in the medical record, that could spell trouble – audit trouble. Reporting on this topic during this edition of Monitor Mondays is Edward Hu,...


CMS Proposes to Implement Home Health Pre-Claim Review Demonstration

Home health providers are now on alert following an announcement on Wednesday that the Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas. In its announcement, CMS issued a notice for a 30-day public comment period. Reporting this developing story during this edition of Monitor Mondays will be William A. Dombi, president of the National Association for Home...


CMS Proposed Rule Intended to Alleviate Regulatory Burdens: Will it Work?

As expected, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group. The broadcast rundown also will include: Monday Focus: Monday Rounds: Hot Topics: Risky...


Compliance During Adversity: Hurricane Florence

As bands of rain and wind from Hurricane Florence are lashing North Carolina, hospitals, health systems, and physician practices are preparing for what is being called the “storm of a lifetime.” Earlier this week, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that Medicaid and Medicare beneficiaries have access to medical care despite the storm, according to a...


Last Chance to Take a Stand: Comment Period for Proposed E&M Changes Ends

Few proposals from the Centers for Medicare and Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E and M) reimbursement changes in the 2019 Medicare Physician Fee Schedule. The outrage has been intense over the plan 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...


Anatomy of an Alleged False Claims Act Violation: The Providence Health & Services Lawsuit

A False Claims Act lawsuit has been filed by Integra Med Analytics against Providence St. Joseph Health, seeking $188.1 million related to alleged upcoding of Medicare claims. According to media reports, Integra made the discovery of allegedly unwarranted major complication and comorbidity secondary codes. In its investigation, Integra identified J.A. Thomas and Associates (JATA) as the clinical documentation improvement consultancy for Providence. The lawsuit alleges Providence and JATA...


CMS, Are You Listening? Podiatrists React Negatively to Proposed E&M Changes

“Podiatrists should not be discriminated against any further. E&M (evaluation and management) requirements are the same as (those for) other providers, and we should be reimbursed justly,” one podiatrist recently wrote, expressing his opposition to the Centers for Medicare & Medicaid Services’ (CMS’s) proposed E&M reimbursement changes in the recently posted 2019 Medicare Physician Fee Schedule. “If Medicare is going to change E&Ms to only two codes, then all specialists should be changed,”...


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 Juliet...


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 and...


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...


340B Drug Discount Program: What Happens Next?

Not unexpected but widely feared among healthcare providers, regulations setting 340B ceiling prices and establishing civil monetary penalties for drug manufacturers that knowingly and intentionally exceed those limits were delayed for the fifth time, until 2019, by the Trump Administration in a final rule published on Tuesday, June 5 in the Federal Register. As the dust settles, America’s rural hospitals are expected to be impacted the most by an apparent lack of government enforcement, as...


Alleged Bias Found in Extrapolation Audits

“Literally billions of dollars a year are being extorted from healthcare providers due to a system of rules, regulations, and guidelines that are not outdated, but just plain wrong,” writes senior healthcare analyst Frank Cohen, director of analytics and business Intelligence for DoctorsManagement in the current edition of the RACmonitor e-News. Cohen joined the Monitor Mondays broadcast to make his case and suggest strategies for improving what he believes is a flawed system of medical...


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...