Over the past six months, in our own client work and published settlements, it is evident that the Department of Justice (“DOJ”) is continuing to focus its audit efforts on patient status. Most recently, a Houston-based health system agreed to pay $1.9 million to resolve allegations that three of its...
Author Archives: proedge
AHA Coding Clinic 1st Quarter 2018 – Key Highlights
Coding Clinic 1st Quarter 2018 (effective with discharges starting February 18) unsurprisingly did not include any significant changes since the previous Coding Clinic release was more extensive. It is a good sign that many of the controversial and pressing issues like COPD with pneumonia sequencing has been addressed and now...
Telehealth Services – Proactively Assess Your Risk
In a recent review of telehealth services, the Office of Inspector General (OIG) found approximately one-third (31/100) of the claims reviewed did not meet Medicare telehealth requirements. Of the 31 cases, the majority were noncompliant because the patients received care in a location not considered “rural.” Institutions/facilities that provide telehealth...
March Regulatory Updates
Review of Statistical Sampling Methods: Pursuant to the regular updates to the Office of Inspector General Work Plan, the Centers for Medicare & Medicaid Services (CMS) is assessing statistical sampling methods used within the Medicare fee-for-service administrative appeal process. Specifically, CMS is reviewing if the Medicare Administrative Contractors and Qualified...
ICD-10 DRG Audit Target Areas – PCS Spotlight – Root Operation: Transfer
Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s...
ICD-10 Audit Target Area – Spotlight on ICD-10-PCS Toe Amputations
Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s...
Is Your Organization a Potential Target for OIG Compliance Review?
As part of a series of hospital compliance reviews, the Office of Inspector General (“OIG”) identifies target hospitals, reviews a probe sample of cases in identified risk areas and determines compliance with Medicare billing requirements. Recent results? Two major hospital systems being asked to pay back large sums of money...
Being Proactive in 2018
At the end of 2017, the U.S. Department of Justice (DOJ) issued its annual recovery statistics – more than $3.7 billion in total recoveries. Of the $3.7 billion recovered, $2.4 billion were associated with settlements and judgements from the healthcare industry. With another record year on the books, healthcare organizations...
Recouping Inpatient Revenue
As hospitals see more and more service lines shift to the outpatient space, it is crucial to understand your data and associated revenue opportunities. For example, with the Final Hospital Outpatient Prospective Payment System Rule removing total knee arthroplasties from the inpatient only list, this could result in a shift...
How Revenue Integrity Audits Improve CDI Programs
Strong provider documentation is only as good as the codes that are assigned and submitted for payment. Well run CDI programs are successful at ensuring that provider documentation accurately represents the conditions treated and procedures rendered during a patient’s stay; but, they are not as successful at ensuring that coders...