OCR’s 2016 guidance on patient access opened up a debate in the industry and brought questions about fulfilling patient access requests to the foreground.
U.S. District Court Judge Rudolph Contreras will hold a hearing December 21 for a lawsuit aimed at halting the CMS payment reduction for hospital outpatient drugs acquired through the 340B program, a policy set to go into effect January 1.
Rush University Medical Center in Chicago did not comply with Medicare billing requirements for 57 inpatient and outpatient claims reviewed by the OIG, according to the OIG’s November report. This resulted in unlawful reimbursement for calendar years 2014 and 2015 with the medical center receiving $814,150 in overpayments, says the report.
In July, Utah pain doctor Jahan Imani, MD, and Intermountain Medical Management, P.C., entered into a nearly $400,000 settlement with the OIG to resolve allegations that Imani’s practice submitted false or fraudulent claims due to improper modifier use for payment by improperly using modifier -59 with HCPCS code G0431.
As federal agencies release new and complex regulations for acute and postacute care facilities, providers are faced with the daunting task of unraveling and complying with the latest changes while ensuring patients receive quality care.
Physicians may be angry at the increased documentation, coding, and billing workflow and compliance activities they must perform to be successful in new reimbursement models. However, to avoid accustations of fraud and upcoding, they must develop their own OIG-recommended compliance plan and be open to rigorous feedback and advice.
Currently, there are no national guidelines for how facilities should assign evaluation and management (E/M) levels in the emergency department (ED). Under Medicare’s ambulatory payment classification (APC) system, facilities create their own internal guidelines for determining the ED visit level, and each facility must follow its own system to demonstrate compliance.
The focus of FY 2018 code changes is specificity. Payers now expect codes to reflect the exact diagnosis and care given before claims will be reimbursed. Increased granularity in both clinical documentation and coding is critical for revenue cycle success in the year ahead.
The largest source of estimated revenue loss in the healthcare midcycle in 2016 was attributed to inadequate documentation, according to a report by the Advisory Board. The report analyzed a range of hospitals in varying size, from 0–500 beds, to determine the impact of midcycle functions. The revenue loss reported for an average 250-bed hospital was $2–$5.5 million.
