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 Carolin ...…

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 patien ...…

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 identifi ...…

“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 r ...…

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 p ...…

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 fin ...…

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 Gr ...…

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 ...…

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 hospit ...…

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 ...…

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 judg ...…

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 ...…

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 Fe ...…

“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 ...…

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 e ...…

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 Monda ...…

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 th ...…

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 t ...…

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 acquisi ...…

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 ...…

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, ...…

Telemedicine, considered to be an electronic lifeline for rural healthcare, is a rapidly growing sector of health care in the United States that has recently gone through a significant expansion. Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac's report on Telemedicine, is attorney Dale ...…

Diving deep into the datasphere, senior healthcare analyst Frank Cohen comes up for air in order to report on a new approach he and his team of data experts have developed to predict the likelihood of an audit. While he claims that his team is not yet predicting billing errors, he does report that many of the variables being used to do so can a ...…

Patients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful of not having their visits covered. Former ED physician-turned healthcare consultant Erica ...…

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’ natio ...…

"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 service ...…

"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 clinica ...…

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 g ...…

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 th ...…

On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? Many of these electronic records are self-populated. So, what happens if you undergo a Recovery Audit Contractor (RAC) aud ...…

Healthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called ...…

“We have been slammed with Medicare Advantage DRG audits,” wrote Sandra from Indiana during last week’s Monitor Mondays broadcast. We asked RACmonitor national correspondent J. Paul Spencer with DoctorsManagement to investigate this issue for this week's episode. Will there be more of these audits? Do these represent low-hanging fruit for audit ...…

Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2018 during this edition of the weekly internet broadcast: Duane Abbey, PhD Janelle Ali-Dinar, PhD Nancy Beckley, MS, MBA, CHC Frank Cohen, MPA William Dombi, Esq. Knicole Emanuel, Esq. Ronald ...…