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

Monitor Mondays

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. Hughes, who was the special guest on this edition of Monitor Mondays.

Other segments to be featured on the broadcast include:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment.
  
• Whistleblower Update: Mary A. Inman, partner at Constantine Cannon's law offices in London, reported on the Aetna lawsuit filed against CVS Caremark accusing the pharmacy benefit manager of the giant retail pharmacy operation of improperly reporting Medicare generic drug prices to the Centers for Medicare & Medicaid Services (CMS).
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported on another example of a potentially troublesome issue that could pose a risk to your facility.
  
• Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.
  
• Medicaid Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, returns to the broadcast with the final installment of her exclusive two-part reporting on a state-by-state review of states' Medicaid regulatory oversight.
  
• Monday Focus: The Bipartisan Budget Act of 2018 contains a number of healthcare issues that have caught the attention of author, educator, and consultant Duane Abbey, who outlined them during the broadcast.

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