All posts by MedManagement Marketing

Continued evolution of CMS guidance and processes

Changes to the Changes—Change Request 8425 Revoked

Effective March 6, 2014 CMS changed the Program Integrity Manual (the handbook for auditors) to give Medicare auditors (including RACs, ZPICs and others) the discretion to deny “related claims” when auditing.  The examples given included a case where an inpatient claim was reviewed and determined to be unnecessary and therefor the associated (“related”) physician claim could also be reviewed and determined Continue reading

Probe and Educate Program Implementation

The past several weeks have been filled with CMS policy and implementation changes: PROBE & EDUCATE PROGRAM CHANGES. On January 31, 2014, CMS announced that the Inpatient Hospital Prepayment “Probe & Educate” review process is extended through September 30, 2014. Medicare Administrative Contractors (MACs) will continue to review claims, and in general, recovery auditors will not conduct post-payment status reviews of inpatient hospital claims for dates of service on and after October 1, 2013 through September 30, 2014. Continue reading

New CMS guidance on audits and the two midnight rule

Audit News.    On Friday, January 31, 2014 CMS extended the Medicare Administrative Contractor (MAC) “Probe and Educate” reviews for an additional six months beyond March 31, 2014 through September 30, 2014.  The release from CMS provides that “MACs will continue to review and deny (emphasis added) claims found not in compliance with CMS-1599—F (commonly known as the ‘2-Midnight Rule’).”  The Recovery Auditors and reviewers other than the MAC will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through September30, 2014, although the Recovery Auditors may continue audits of inpatient admissions prior to October 1, 2013 and may audit all inpatient admissions for issues other than inpatient status issues.

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New Year’s Resolutions

2014–The New Year– Some familiar challenges, and some new ones created by changing health care regulations and policies.  Because the change is so rapid, information we provide may be outdated by the time this newsletter reaches you.  We thought it might be helpful to share ideas for New Year’s Resolutions to help staff manage the pace and nature of change even as “specifics” change:

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ALERT: “Pause” on RAC audits of short stays

Yesterday, September 26, 2013, CMS made a major announcement.

For short stays from October 1, 2013 through December 31, 2013 CMS instructed auditors:

  • Not to review claims spanning more than two midnights after  the formal inpatient order “for appropriateness of patient status.”
  • RACs will not review stays less than two midnights.
  • MACs will conduct a “probe” audit of 10—25 claims for each hospital on hospital stays of one midnight or less after the inpatient order.
  • RACs and MACs will not audit CAHs. Continue reading

Client portal facilitates the data flow of physician advisor services


med-news-1 The screenshot above is an example of MedManagement’s client portal.  The link to the portal is on the MedManagement website,  For direct access to the portal, click here.  To maintain the security of the portal, the client notifies MedManagement of the individuals who require access rights to the portal.   A user name and password are then assigned by individual. The portal is a valuable tool in facilitating the exchange of data between MedManagement and its clients.  The portal provides clients quick access to the status of all concurrent utilization including level of care Continue reading

Redefining “admission?”: Proposed medicare hospital inpatient prospective payment systems (CMS-1599-P)

CMS Proposed Rule 1599 (PR1599) published in the Federal Register on May 10, 2013 proposes significant changes to hospital bed status determinations.  Although the proposed rule is submitted as a “clarification” of existing policy and not a change, there are significant ramifications as to changing presumptions with respect to the timing of orders and decisions.  The proposed rule will apply to discharges on or after October 1, 2013.  It is important to remember that PR1599 is proposed, and not final.  However, the changes in the proposed rule make it clear that the government will continue to reduce or eliminate inpatient payment for short, medically necessary inpatient stays unless the timing and content of documentation clearly supports the admission decision.   Proper documentation, timely prepared is critical for the hospital to receive appropriate reimbursement. Continue reading