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Understanding the ZPIC Audits

April 23, 2014


Before Health Information Management (HIM), Revenue Cycle Management (RCM) and Compliance Officials start to do the happy dance since they have a break from the Recovery Audit Contractors (RAC) auditors, they should consider using this pause to ensure everyone is on track regarding another, and more serious, the type of auditing underway.


UConn Looks for Performance Wins Beyond the Basketball Court

April 16, 2014


A school whose early mission was agriculture, the University of Connecticut (UConn) has repeatedly represented some of the nation’s best men and women basketball players and coaches. The women’s team again shares a national title with the men as it did in 2004.  Since 1999, the Huskies' men and women have made a combined 17 appearances at the Final Four, more than any other school.


Challenges of Health Information Exchanges

April 9, 2014


The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, provided funding for various activities intended to promote the adoption and meaningful use of certified health information technology.  HITECH identified the importance of the electronic exchange of health information by requiring it as a key element in the definition of meaningful use of certified electronic health record (EHR) technology.1  Specifically, in order to be a meaningful EHR user, providers are to demonstrate that their certified EHR technology is able to electronically exchange health information to improve the quality of health care, such as promoting care coordination.  As such, electronic exchange is of key importance to the U.S. Department of Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services (CMS) EHR programs.


Congress Passes SGR Fix Along With Delays in ICD-10 and Two-Midnight Rule

April 2, 2014


Early Monday evening the U.S. Senate voted to pass the House legislation that will delay the upcoming 24 percent cut in Medicare payments for a one-year “fix” for reimbursement of physician services from March 31, 2014, to March 31, 2015.1  Since 1997, the sustainable growth rate (SGR) has been a thorn in the side of physicians, Centers for Medicare & Medicaid Services (CMS) and Congress.  This latest version of the “doc fix” was voted out of the U.S. House of Representatives on March 27, 2014 to temporarily delay the looming 24 percent cut in Medicare payments for physician services to March 31, 2015, which was set to go into effect on March 31, 2014.2


Several Lessons to Learn from the Mystery of Flight 370

March 26, 2014


Often crisis situations offer a healthy challenge to our creativity, sense of humanity and responsibility.  History has proven that in every industry, from automobile to zoos, executive management and their organization need to be prepared to respond to a crisis situation.  The media frenzy from CNN to the free-fall tweeting of social media; can quickly propel a crisis into a mega-crisis based on the chatter of speculation and the verification, or in the case of Flight 370, non-verification of the facts.  In any disaster from Katrina to Sandy, Toyota floor mats to GMs ignitions, we must ask questions…why, when, what, how?  The many questions surrounding the mysterious event of Flight 370 will continue to be asked, even if we never have solid answers—and likely even if we do.


RAC Audits Suspension May Ease the Two-Year Hearings and Appeals Backlog

March 19, 2014


In a February 17 announcement that took the healthcare community by surprise, the Centers for Medicare & Medicaid Services (CMS) ordered Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) to cease in their requests for additional documentation requests (ADRs) effective February 28, 2014.  As the current RAC contracts are coming to a close, and with CMS under intensifying pressure from healthcare providers, coupled with a massive backlog of cases pending appeal, CMS stated that, “This will give providers a much-needed “intermission” in recovery audits until CMS finalize and select winning bidders for the next round of contracts."1


President’s Budget Increases Funds for Office of Civil Rights Coincides with Announcement of New Round of Audits

March 12, 2014


The Department of Health and Human Services’ Office of Civil Rights (OCR) published on February 24, 2014 an announcement that it will resume its HIPAA compliance audit program. This time around OCR is expanding the program to include both covered entities and business associates.  OCR’s audit plan will start with a survey of 1,200 organizations out of which some number will be selected to be audited. The survey “will gather information about respondents to enable OCR to assess the size, complexity and fitness of a respondent for an audit,” according to the Notice. “Information collected includes, among other things, recent data about the number of patient visits or insured lives, use of electronic information, revenue and business locations.”  Approximately two-thirds of those surveyed will be covered entities, and the remainder, business associates. The Notice stated that the OCR would be accepting comments on its plan until April 25, 2014.1 The OCR’s mandate by the Health Information Technology for Economic and Clinical Health Act (HITECH) includes developing national standards for the privacy of protected health information, the security of electronic protected health information and breach notification to consumers. HITECH also requires OCR to perform periodic audits of covered entity and business associate compliance with the HIPAA Privacy, Security and Breach Notification Rules.


Expanding the DRG Window

March 5, 2014


The Diagnosis Related Group (DRG) “DRG window policy” defines when outpatient services related to inpatient admissions are not paid for separately, but rather are considered to be included in the inpatient lump-sum payment. Under the current DRG window, Medicare and beneficiaries do not pay separately for related outpatient services delivered within three days of an inpatient admission in a setting owned by the admitting hospital. Services that are provided by hospitals that share a common owner (i.e., multiple hospitals owned by the same corporation, hereinafter, called affiliated hospitals) are not subject to the DRG window. In a February 2014 report, the Office of Inspector General (OIG) released the results of their study regarding the substantial savings to Medicare if the DRG window were expanded.


Understanding Administrative Simplification Operating Rules

February 26, 2014


The Centers for Medicaid and Medicare (CMS) offer Administrative Simplification as an initiative to support eHealth.  eHealth is best defined as a healthcare practice that utilizes electronic information and communication to improve the quality and delivery of health care.  eHealth is comprised of the business processes that support electronic information exchange and administrative efficiencies.  Patients, caregivers, communities, providers, healthcare facilities and government encompass the policies and standards of eHealth.  Administrative Simplification is achieved through standardization with a goal to lower the cost of care by reducing the inefficiencies that increase cost and lower the quality of care.


Medicare Post-Acute Care Episodes and Payment Bundling

February 19, 2014

The Centers for Medicare & Medicaid Services (CMS) released a report for the Medicare & Medicaid Research Review (MMRR) to examine service use in an episode of acute and post-acute care (PAC) under alternative episode definitions. The report also looks at geographic differences in episode payments.


Office of Inspector General 2014 Work Plan

February 12, 2014


The Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for Fiscal Year 2014 provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year 2014. The Work Plan describes the primary objectives and provides for each review its internal identification code, the year in which we expect one or more reports to be issued as a result of the review, and indicates whether the work was in progress at the start of the fiscal year or will be a new start during the year. When reports are issued, they are posted to OIG's website.


The Joint Commission Requires Hospitals to Improve Their Alarm Systems

February 5, 2014


The Joint Commission announced in December 2013 the release of the “R3 Report”1 for the new National Patient Safety Goal (NPSG) in an effort to require accredited hospitals and critical access hospitals to improve the safety of their clinical alarm systems.  The goal addresses clinical alarms that can compromise patient safety if they are not properly managed.


Data Breaches Continue to Take Center Stage

January 29, 2014


In light of the frequency with which data breaches come across the front page of prominent news sites, we felt it opportune to remind our readers of the importance of compliance with State and Federal privacy laws.  Namely, the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its impending regulations.  It is all too easy for medical practices and health systems to suffer data breaches, and the financial consequences can be severe.  When a breach of patient data is found and reported, healthcare providers and legal business associates can be liable for penalties of up to $1.5 million for violations of a single HIPAA provision each year.


Uncompensated Care Skyrockets to $45.9 Billion

January 22, 2014


An annual survey of hospitals completed by the American Hospital Association (AHA) indicates uncompensated care provided by U.S. hospitals rose from $4.8 billion (11.7%) in 2012 to a massive $45.9 billion.  AHA is the nation’s most comprehensive source of hospital financial data, and compiles aggregate information annually on the level of uncompensated care.


Survey Results Indicate the Healthcare Industry is Falling Behind with ICD-10 Compliance Readiness

January 15, 2014


The Workgroup for Electronic Data Interchange (WEDI) is a leading authority on the use of Health IT to improve the exchange of healthcare information.  On December 13, 2013 the group announced results from the October 2013 WEDI ICD-10 Readiness Survey to the Centers for Medicare & Medicaid Services (CMS).  The report discloses the Healthcare Industry is not making the grade when it comes to the amount of progress needed for a smooth transition to ICD-10 in October 2014.


CMS Proposed Regulations to Address Emergency Preparedness for Medicare, Medicaid Providers

January 8, 2014


On December 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule that would add emergency preparedness requirements to the conditions of participation and conditions of coverage for a wide range of providers and suppliers. Affected organizations include hospitals (including critical access hospitals), long term care facilities, ambulatory surgical centers, hospices and home health agencies, outpatient rehabilitation providers, programs of all-inclusive care for the elderly, organ procurement organizations, religious non-medical health care institutions, community mental health centers, rural health clinics and end-stage renal disease facilities.


CMS Makes Outpatient Facility Policy and Payment Changes

December 18, 2013


In the Centers for Medicare & Medicaid Services (CMS) final calendar year (CY) 2014 hospital outpatient and Ambulatory Surgical Center (ASC) payment rule [CMS-1601-FC], CMS notified hospitals and ASC that they will replace the current five levels of hospital clinic visit codes for both new and established patients with a single code describing all outpatient clinic visits. “A single code and payment for clinic visits is more administratively simple for hospitals and better reflects hospital resources involved in supporting an outpatient visit,” said a release from CMS.1 The current five levels of outpatient visit codes are designed to distinguish differences in physician work.


How the Physician Value-Based Payment Modifier Program will Affect the 2014 Medicare Physician Fee Schedule

December 11, 2013


The Physician Feedback/Value-Based Modifier Program is provided by The Centers for Medicare and Medicaid Services (CMS) to provide comparative performance information to physicians. CMS is geared towards improving the quality and efficiency of medical care by providing meaningful and actionable information to physicians so they can improve the care they furnish. Physicians can find value rather than volume moving towards physician reimbursement.1


The Office of Inspector General Strategic Plan for Fiscal Years 2014-2018

December 4, 2013


The Office of Inspector General (OIG), United States Department of Health and Human Services (HHS) Strategic Plan focuses on the four goals in the white box shown here. With a return of more than $7 for every $1 invested, no one can doubt the impact the OIG has on saving health care funds and reducing fraud, waste and abuse. The Strategic Plan highlights key strategies and indicators for attaining and measuring results for the next few years.


Medicare Advantage Funding, Open Enrollment, and United Healthcare Plans to Drop Doctors

November 27, 2013


Medicare Open Enrollment for 2014 ends December 7th, 2013 and many beneficiaries that were hoping to stay with their current Medicare Advantage Plan, are scrambling to learn if their doctor is still going to be part of their plan. The reason is some Medicare Advantage plans, with United Healthcare being the largest and most significant one, are in the process of dropping a significant number of doctors from their Medicare Advantage plan networks beginning next year.


Three Things to Remember Regarding Meaningful Use in 2014

November 20, 2013


As we approach the New Year, there are three major factors to keep in mind as you continue (or begin) the EHR Incentive Program popularly referred to as Meaningful Use. These updates can adversely affect your success with the attestation process and, ultimately, your CMS incentive. In addition to all the other supportive material available, keep these three tips on the top of your list to ensure your compliance with the EHR Incentive program.


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