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
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.
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 Because the change is so rapid, information we provide may be outdated by the time this newsletter reaches you.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:
2014 IPPS: REAL WORLD EXPERIENCE OF CASE MANAGERS “IN THE TRENCHES” QUESTIONS (A/K/A QUESTIONS WE HAVE RECEIVED SINCE OCTOBER 1)
In an effort to continue to assist clients with implementation of the requirements set forth in the 2014 IPPS we share below questions that have arisen recently and answers based on our interpretation. Continue reading
On Friday, November 1, 2013, CMS described its approach to probe audits which will be conducted through March 31, 2014. It is important to be prepared to avoid “repeat” or broader future audits by the MAC. The Recovery Auditors (RACs) will be authorized to review short stays in 2014, so compliant processes are important to prevent future recoupments as well. Continue reading
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
As hospitals continue to digest the 2014 Hospital IPPS for Acute Care Hospitals, many questions have arisen. In this newsletter we will present a sampling of the questions we have heard from our clients and other interested parties. CMS has promised further guidance, and we will share it with you as it is issued. Continue reading
The screenshot above is an example of MedManagement’s client portal. The link to the portal is on the MedManagement website, www.medmanagementllc.com. 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
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
The job of handling denials and appeals has become more complicated after the CMS Ruling 1455 was published on March 13, 2013. The Administrative Law Judges (ALJs) did not take long to respond and add additional complexities to the process. Continue reading