Medicare Compliance & Reimbursement
New Review Entities on the Horizon
CMS proposes switch.
You’ll be getting medical reviews from a new entity for 2016. The Centers for Medicare & Medicaid Services (CMS) has proposed to switch from Medicare Administrative Contractors (MACs) to Quality Improvement Organizations (QIOs) to provide the first line medical reviews regarding questioned admissions.
QIOs, private contractors charged with monitoring the quality of care provided to Medicare beneficiaries, are a good choice for first line reviews as they (in their various program incarnations), have generated a respectable track record across numerous clinical review issues for more than 30 years, says Michael Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, Mass. Quality Improvement Organizations historically have not been involved in enforcement actions and have more collaborative relationships with providers than the RACs which are incentivized by finding errors in audits.
The proposed rule states that reassignment of inpatient admissions to Quality Improvement Organizations will take effect October 1, 2015, even if the other modifications to the two-midnight rule are not implemented. RACs will remain authorized to review hospitals with consistently high rates of denials from Quality Improvement Organizations, notes Granovsky.
CMS is continuing to limit RAC authorities in response to provider objections and the unreasonable multi-year backlog of RAC appeals at the Administrative Law Judge (ALJ) level. Among the proposed changes are:
Medicare Compliance & Reimbursement
- Reimbursement:
'Prosecutorial Discretion' Could Save You from Overpayment Penalties -- Here's How
Could your diligent and faithful actions bail you out on day 61? You must start [...] - Overpayments:
Look Ahead: 3 Potential After Effects from Overpayment Case
Plus, what steps you should take now to protect yourself from enforcement actions. As the [...] - Audits:
Does Your Documentation Support Services Billed?
E/M coding still tripping up reimbursement. If 73.3 percent of your claims were denied or [...] - Medical Reviews:
New Review Entities on the Horizon
CMS proposes switch. You’ll be getting medical reviews from a new entity for 2016. The [...] - PHI:
Keep Looking for New Ways To Secure Data
Growing number of breaches in 2015 indicate continuing vulnerability. Accidental losses of laptops, external hard [...] - Industry Note:
White House: CMS Not Making Enough Effort to Fix Errors
Although it might feel like CMS is doing everything it can to keep money [...] - Industry Note:
Cost Report Changes Afoot for Variety of Hospice Types
The Centers for Medicare & Medicaid Services (CMS) may have issued freestanding hospices’ new cost [...] - Industry Note:
Submit F2F for All Reviewed Claims -- Even Recerts
Don’t forget that medical reviewers will be poring over your claims for face-to-face documentation — [...]
