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Medicare Recovery Audit Contractor Program A Costly Burden to Hospitals

May 27, 2015


The American Hospital Association (AHA) recently released the results from a September 2014 survey of the Medicare Recovery Audit Contractor (RAC) program.  The report, “The Real Cost of the Inefficient Medicare RAC Program" is based on responses from 402 hospitals that participated in the survey.  In addition, the AHA reviewed Fiscal Year 2013 RACTrac data submitted in all four quarters by 547 hospitals.


OIG: Practical Guidance for Health Care Governing Boards on Compliance Oversight

May 20, 2015


As the government continues to dedicate substantial resources to combat fraud and abuse in the healthcare industry, and the number of private whistleblower suits continues to increase, the need for a robust compliance program with appropriate board-level oversight is greater than ever.  On April 20, 2015, the Office of the Inspector General of the U.S. Department of Health and Human Resources (OIG), in collaboration with the American Health Lawyers Association, the Association of Healthcare Internal Auditors and the Health Care Compliance Association published Practical Guidance for Health Care Governing Boards on Compliance Oversight (Guidance) directed in particular at healthcare organizations’ boards of directors and trustees regarding compliance oversight.


The Tenth Amendment & Telehealth Expansion Opportunities: State-by-State within the United States

May 15, 2015


Healthcare is a global industry. We have medical devices and pharmaceuticals being developed in Europe and Asia.  We have coding and billing being performed in India, Philippines and other foreign countries. The rapid evolution of technology has given us treatments hardly conceivable ten years ago.  The Affordable Care Act (ACA) moved the United States forward in providing healthcare to all its citizens. Yet, many aspects of how that care is delivered and reimbursed are based on State regulations.


The Affordable Care Act Impact on Medicaid Programs

May 6, 2015


As of March 2015, twenty-eight states and the District of Columbia had implemented the expansion of Medicaid under the Affordable Care Act (ACA) to cover adults under age 65 with incomes up to 133 percent of the Federal Poverty Level.  There is no deadline for when a state must decide whether to expand Medicaid and states continue to consider their options.  The enrollment impact of the Medicaid expansion varies; some of these states had expanded coverage to parents and other adults at income levels above the level required under federal law before the ACA.  Many other states previously covered parents only at the minimum required income levels and often did not cover other adults without disabilities who are under age 65.


Provider-Based Departments are on the Radar

April 22, 2015


For the second time in six months, a hospital has settled a case over alleged violations of Centers for Medicare and Medicaid Services (CMS) provider-based regulations. Hospitals are vulnerable in this area because of the many technical requirements for provider-based status.


Point-of-Service Collections Benchmarking

April 15, 2015


The Association of Healthcare Access Management (NAHAM) promotes best practices, standards and subject matter expertise to their members to influence and promote high quality delivery of Patient Access Services.  In early January 2015, NAHAM released 22 standard patient access key performance indicators (KPIs) called the NAHAM AccessKeys®.  The AccessKeys are available to NAHAM members and provide a better way to track and measure the performance of patient access.  AccessKeys were created for six key areas: Collections, Conversions, Patient Experience, Process Failure and Resolution, Productivity and Quality.  Prior to the establishment of the NAHAM’s recognized standards, it was difficult to produce an accurate comparative benchmark because patient access departments lacked a level of standardization in terms of definitions and measurements in use at their facility.  The NAHAM AccessKeys definitions of what is or isn’t included in certain processes will further assist patient access departments in determining how well various functions are being performed in comparison to other hospitals.


April is National Workplace Violence Prevention Month

April 8, 2015


Healthcare and social service workers face a significant risk of job-related violence. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”1 According to the Bureau of Labor Statistics (BLS), 27 out of the 100 fatalities in healthcare and social service settings that occurred in 2013 were due to assaults and violent acts.2


Coverage and Reimbursement for Genetic Testing

April 1, 2015


There is an adage that things happen in three.  Whether they are good or bad luck, rare finds or everyday bargains, it seems that when something happens three times in a row, people tend to pay attention to it.  Angelina Jolie's announcement of her additional proactive surgery to prevent cancer based on the BRCA1 and BRCA2 genes identified through genetic tests was my recent number three.  The first occurrence happened the week before on a Park City ski lift when a young man identified himself as a biomedical researcher working for a Salt Lake City company that does BRCA testing.  The second occurrence was over the weekend when a friend shared her recent breast cancer diagnosis following a 12-month period in which both her mother and sister were also diagnosed.  Then the news broke about Jolie’s decision.  Within a span of ten days, breast cancer and genetic testing were staring me, and likely many consumers, providers and payers in the United States (U.S.), in the face.


It’s a Yellow Brick Road Journey to a Shared Nationwide Interoperability Roadmap

March 25, 2015


The Office of the National Coordinator for Health Information Technology (ONC) recently laid out their draft vision for a future health information technology (IT) ecosystem where electronic health information (EHR) is appropriately and readily available to empower consumers, support clinical decision-making, inform population and public health and value-based payment, and advance science.


Healthcare March Madness

March 18, 2015


March Madness is a nickname forever fixed to the single elimination National Collegiate Athletic Association (NCAA) Division I college basketball tournament that occurs each spring in the United States.  As millions of Americans scramble to fill out their March Madness brackets, those of us in healthcare get to experience our own version.  With another deadline fast approaching for eligible individuals to enroll in the Affordable Care Act (ACA), the White House’s March Madness campaign is a chance to get the attention of young people, especially young men to sign up for healthcare before the March 31 deadline.  Anyone in need of affordable coverage should head over to HealthCare.gov and #GetCoveredNow.  Anyone that is already covered can help spread the word by voting for your favorite reason to get covered.  While you are at you can check out President’s Obama bracket picks at https://www.whitehouse.gov/acabracket.


ICD-10 Transition Aided by Computer Assisted Coding

March 11, 2015


Medical coding is a key step in the revenue cycle billing process. When patients receive health care services in a physician’s office, hospital or outpatient facility, each service provided must be documented in the form of a medical record.  The role of a medical coder is to abstract the information from the medical record, assign the appropriate ICD-91 Diagnosis and ICD-9 and/or CPT procedure codes and create a claim that is billed to a commercial payer, Medicare, Medicaid or directly to the patient.


CMS Delays Final Rule on Medicare Overpayments yet Providers are Still Obligated to Make Timely Refunds

March 4, 2015


The Centers for Medicare and Medicaid Services (CMS) has delayed the publishing of its final rule on procedures and policies for reporting and returning Medicare overpayments for at least another year, according to a notice published February 13 in theFederal Register.  “Based on both public comments received and internal stakeholder feedback, we have determined that there are significant policy and operational issues that need to be resolved in order to address all of the issues raised by comments to the proposed rule and to ensure appropriate coordination with other government agencies,” CMS officials wrote.


Hospice Claims Under Inspection

February 25, 2015


Medicare hospice care is intended to help terminally ill beneficiaries continue life with minimal disruption and to support families and caregivers.  Care may be provided in various settings, including a private home or other places of residence, such as an assisted living facility (ALF).  This care is palliative, rather than curative.  It includes, among other things, nursing care, medical social services, hospice aide services, medical supplies (including drugs and biologicals) and physician services.  The beneficiary waives all rights to Medicare payment for services related to the curative treatment of the terminal condition or related conditions but retains rights to Medicare payment for services to treat conditions unrelated to the terminal illness.


Since 1990 the Medicare Program has been Designated as a “High-Risk”

February 18, 2015


The Government Accountability Office (GAO) has released its latest update to its “High-Risk Series” reports, which again lists Medicare as a high-risk program, in part because of the program’s substantial size and scope, and its wide-ranging effects on beneficiaries, the health care industry and the U.S. economy.  In fiscal year 2014, Medicare outlays will total more than is projected to be spent on defense ($594 billion) and almost double federal spending on Medicaid ($305 billion).  Medicare spending will account for nearly 17 percent of the approximately $3.5 trillion in federal outlays.  The report recommends continual attention to the following five areas.


The President’s Precision Medicine Initiative

February 11, 2015


President Obama stated during his 2015 State of the Union address that he wanted the United States to lead a new era of medicine—an era that delivers the right treatment at the right time.  The President’s initiative was labeled as “precision” or personalized medicine.  Precision medicine is a term for tailoring treatments to an individual’s genetic makeup, microbiome and other factors.  In a call with the press in late January, Jo Handelsman, Associate Director for Science in the White House Office of Science and Technology Policy called precision medicine as “a game changer” that “holds the potential to revolutionize the way we approach health in this country and ultimately around the world.”


HHS Scores Second Win with Primary Care Quality and Value Initiatives

February 4, 2015


Last week we reviewed Health and Human Services (HHS) Secretary Sylvia M. Burwell’s January 26, 2015 announcement on specific goals and a timeline for shifting Medicare reimbursements from the traditional fee-for-service (FFS) model to a quality or value-based model.  The  HHS team is optimistic in achieving its goals, noting in its press release that it has “already seen promising results on cost savings with alternative payment models” through a combined total program savings of $417 million to Medicare due to existing ACO programs.  Moreover, it “expects these models to continue the unprecedented slowdown in health care spending.”1


The State of the Union and Healthcare

January 28, 2015


Like many with careers in healthcare delivery or administration, we anxiously listened to each word of President Obama's 2015 State of the Union address to see what the White House agenda may be for the remainder of his Presidency.  While guarantees of sick days, paid maternity leave, along with the successful battle to control Ebola, and find cures to other deadly diseases, were mentioned, the President’s address seemed light on healthcare, especially considering the turmoil over the past year with the Affordable Care Act (ACA).


The Growth of Telehealth/Telemedicine Spawns New Regulations

January 21, 2015


Many people, even in the healthcare industry, tend to speak about telehealth and telemedicine as if they are the same thing.  Actually, outside of the general notion that they involve transmitting health-related information, they are different concepts.  Currently, there is no one best definition of these two terms, resulting in some crossover and variances in regulations between federal and state governments.


Medicare Payment Advisory Commission Begins Work on Next Year’s Recommendations

January 14, 2015


The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.  The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.


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