Experts in healthcare reimbursement and regulation,
providing customized consulting
and education services.

Training Programs

We bring the experts to you with a range of on-site education options and bootcamp style programs that teach how a firm grasp of the rules leads to operational excellence.

More information »

Audits & Assessments

Our team of specialized regulatory specialists can assist your organization in revving up your revenue cycle by auditing and assessing key processes for coding and billing.

More information »

Regulatory Monitoring

Our team is available for ongoing regulatory watchdog services that answer your questions and offer you the latest Medicare news, analysis and operational guidance.

More information »

Nov
20

New report reveals $47 billion in Medicare fraud

By Compliance Monitor · Comments (0)
Email This Post Print This Post
The government paid over $47 million in questionable Medicare claims – nearly three times the amount from last year, according to a new federal report, obtained by The Associated Press (AP).
 
The improper payments are the largest waste of taxpayer dollars in the $440 billion Medicare program’s 20 year history, according to the report.
 
According to the AP, the Health and Human Services Department’s stricter documentation requirements caused the increase, not an actual rise in Medicare fraud. The AP reports that in the near future, President Obama will announce new initiatives to defend against Medicare fraud, including the launch of a government Web site detailing healthcare spending and improper payments by various health agencies.
 
The Obama administration has set its goal of reducing improper Medicare payments at 9.5%. This projected target would save taxpayers a total of $9.7 billion.
Nov
19

Tip: Submitting claims for laboratory services

By Compliance Monitor · Comments (0)
Email This Post Print This Post
Your hospital should ensure that all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends that your hospital’s written policies and procedures state that:
 
  • The hospital bill for laboratory services only after they are performed
  • The hospital bill only for medically necessary services
  • The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
  • The current procedural terminology or Healthcare Common Procedural Coding System code used by the billing staff accurately describes the service ordered
  • The coding staff submit only diagnostic information obtained from qualified personnel and contact the appropriate personnel to obtain diagnostic information in the event that the individual who ordered the test has failed to provide such information
  • The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
  • Routine audits be conducted to assess your billing compliance with the regulations
This week’s tip was adapted from The Compliance Officer’s Handbook 2nd Edition. For more information about the book or to order your copy, visit the HCMarketplace.
Comments (0)
Nov
18

Revenue Cycle Institute releases free RAC Preparedness Benchmarking Report

By Andrea Kraynak, CPC-A · Comments (0)
Email This Post Print This Post

Budgets are tight, but it seems that many healthcare providers are aware that setting aside resources to prepare for RAC audits is non-negotiable.

HCPro’s Revenue Cycle Institute examined this concept as a part of its recent nationwide survey of RAC readiness. The study, which was released recently, garnered more than 700 participants from all four RAC jurisdictions. The respondents hailed from various size healthcare providers: 25% came from hospitals with fewer than 100 beds, another 25% came from hospitals with more than 400 beds, with the remaining 50% falling in between. Approximately 14% of respondents had taken part in the RAC demonstration project.

“Respondents seem to have their RAC preparations well under way, although it’s not surprising that they are struggling with resources to devote to preparation,” according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, and author of the “RAC Preparedness Benchmarking Report,” which details the full results of the survey. Read More→

Categories : RACs
Comments (0)
Nov
17

Region D RAC approved to audit modifiers -TC and -26

By Andrea Kraynak, CPC-A · Comments (0)
Email This Post Print This Post

HealthDataInsights has been approved by CMS to audit for inappropriate billing related to the use of modifiers -TC and -26 on Part B claims in all RAC Region D states.

The new issue is as follows:

  • Global vs TC/PC. An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service.

To see an updated list of issues approved in your area, visit the Tools section of the Revenue Cycle Institute Web site, and download our chart of approved RAC issues.

Comments (0)
Nov
17

More on deductibles and coinsurance

Email This Post Print This Post

By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.

CMS recently published the Part A deductible and coinsurance and Part B deductible amounts for CY 2010. For most covered inpatient stays, as well as covered outpatient services, Medicare does not pay the entire Medicare allowable for those stays or outpatient services. Beneficiaries generally are responsible for a portion of the Medicare allowable in the form of deductibles and/or coinsurance.

Under Part A, Medicare beneficiaries are entitled to 90 regular benefit days per benefit period. Regular benefit days renew whenever a new benefit period begins. That is, a patient once again has 90 covered inpatient days every time a new benefit period begins.  Medicare beneficiaries are also entitled to 60 lifetime reserve days, which may be used after regular benefit days for that benefit period have been exhausted. Lifetime reserve days do not renew. Once used, they are gone forever. 

Click over to the MedicareMentor Blog to read more.


Categories : Medicare compliance
Comments (0)
Nov
17

CMS Public Events: Hospital Open Door Forum

Email This Post Print This Post

The next Hospital & Hospital Quality Open Door Forum is scheduled for 2 p.m. Eastern, Thursday, November 19. To access the call, 800/837-1935 and reference conference ID: 34708559.

A transcript and audio recording of the conference call will be available to MedicareFind subscribers approximately one week after the Open Door Forum is held.

Nov
17

Refresh your knowledge of core concepts for coding accuracy

By HIM Connection · Comments (0)
Email This Post Print This Post
Clinical knowledge is an essential element for capturing severity and MS-DRG assignment, according to Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM at Kaiser Permanente in Oakland, CA. “When we’re talking about DRG changes and coding changes, it’s important to enhance clinical knowledge,” she said.
 
Additionally, refresh your knowledge of the following core concepts for coding accuracy:
  • Case-mix index. Track this monthly and look for changes. What is your highest-volume DRG, primary diagnosis, and secondary diagnosis?
  • Accurate and complete coding. Know the Uniform Hospital Discharge Data Set definition of principal diagnosis: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
  • Physician documentation. This is key to accurate code assignment. Have your clinical documentation improvement specialist determine where improvements are needed.
  • Coding audits. Perform audits regularly to evaluate accuracy and potential over- or undercoding.
“These are great actions to take to ensure accuracy in documentation, case-mix index, and certainly your MS-DRGs,” Bryant said.
 
Editor’s note: This tip is adapted from the November 2009 issue of Briefings on Coding Compliance Strategies.
Comments (0)
Nov
13

Region D RAC adds new DME issue

By Andrea Kraynak, CPC-A · Comments (1)
Email This Post Print This Post

HealthDataInsights (HDI) added another new issue approved for RAC audits in all region D states to its Web site.

The new issue is as follows:

  • DMEPOS while patient is in a covered Part A inpatient hospital stay.

The Web site provides the following explanation of the new issue: Read More→

Comments (1)