Warning: Auditors Will Target SNF Patient Conditions, Not Services and Time Rendered

Published: Wed, 09/25/19

Say goodbye to RUG-IV, and hello to the Patient-Driven Payment Model (PDPM). This is a daunting task, not for the faint of heart. Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to a successful Recovery Audit Contractor (RAC) audit.

Medical billing and coding is complicated, but it is critical to a practice's success

Billing is essential to any business, but few must contend with the challenges associated with medical billing. Healthcare organizations are required to navigate a labyrinth of insurance payers, patient copays and regulatory requirements, which often leads to lengthy periods between services...

External Claim Audits Key to Strong Hospital Compliance Programs

Hospital compliance programs have the potential to prevent costly denials and healthcare fraud investigations by conducting audits of high-risk areas, including coding, clinical documentation, and medical billing. Yet hospitals are still leaving millions of dollars on the exam room table.

Court decision upholds provider sovereignty over determinations of medical necessity

Last week, the 11th Circuit (the federal appeals court for the Southeastern United States) issued a decision in the AsceraCare case. We have been waiting for this decision since the case was argued two and a half years ago. The key question in the case is: if a hospice provides care to a patient based on...

The Coding Conundrum: Vaping-Related Lung Injury

Physicians work hard to generate revenue, and with slim operating margins, they don’t want to contend with costly recoupments. Compliant coding and billing helps them avoid the focus of a pre- or post-payment audit. This article discusses four services that...

The Coding Conundrum: Vaping-Related Lung Injury

The Centers for Disease Control and Prevention (CDC) is currently investigating vaping-related illnesses that have recently been reported. There are 450 confirmed or suspected cases in 33 states. The first death was reported on Aug. 23, 2019, in Illinois. The concern has escalated to the point that CDC...

Identifying & Addressing Common Medical Billing Errors Pre- & Post-Payment

It is estimated that as high as 80 percent of medical bills contain errors.¹ As healthcare costs continue to rise, so too is the need for healthcare payers to reduce overspending resulting from avoidable billing errors and improper claims reimbursement.

CMS Increases Scrutiny of Owners through Medicare Provider Enrollment Process

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on September 5, 2019, intended to address program integrity and vulnerability issues. The Office of the Inspector General (OIG) testified before Congress in 2011 that fraud schemes relied on the use of networks of affiliations among...