“Finally Friday!” Final Word on Transmittal 541 and “Clawbacks”

FRIDAY September 19, 2014

The Final Word on “Clawbacks”

Transmittal 505/534/540/541

Watch the Replay and Get the Handouts

transmittal 505|appeal academy|finally friday

Project FAIL: when a government project fails, they just change it’s mission – reset the parameters, the expectations. That’s what happened with this tank, the Sergeant York Gun System, and it reminds us of what’s going on now, with the CMS Transmittals 505, 534, 540, 541, et al…

With all the recent changes by CMS – from the IPPS Final Rule, the RAC contract renewals and delays, the OMHA fiasco, to the Global Settlement offer – nothing is more confusing than the bevy of transmittals, rescindments and revisions for recoupment of physician fees when related to a postpayment denial of a Medicare inpatient hospital claim.

The whole thing reminds me of another government blunder, albeit in a wholly different industry. Ever hear of the Sergeant York Anti-Aircraft Gun? It was basically a tank, originally designed to guard other tanks by shooting down attacking aircraft. Tests proved it unable to shoot down jets, so its mission was changed… it was now tasked with shooting down attacking helicopters. It failed that too, even failing to shoot down hovering helicopters. Eventually, the program was cancelled, after expending $6.79 billion and another $54 million just in testing, in a failed attempt to salvage something from the program. The prototypes became targets on air force bombing ranges. Would that CMS Transmittals could be repurposed in this same way…

This week, we again shared a powerpoint presentation offered by Dr. Mike Salvatore, plus we offered our own presentations to cover four subjects:

  • Dr. Ron Hirsch gives a brief history of all the Transmittals,
  • We list the final known facts about the current policies now in effect,
  • We explain our calculations for determining surgery reimbursements at risk, and
  • Dr. Deepak Pahuja reviews the possible future risk for hospitalist billings.

Deepak Pahuja, MD, MBA – Practicing Hospitalist, Chief Medical Officer at Aerolib Healthcare Solutions, Physician Advisor for Hospital Medicare compliance

To help with looking at the possible future impact on hospitals as it relates to hospitalists and/or owned physician practices, we’ve asked Dr. Deepak Pahuja, CEO & CMO at Aerolib Healthcare Solutions to come back and help us see exactly what the impact can be on a hospitalist group. That is, just how bad can this be for a hospital, and for a group of hospitalists employed by a hospital? Dr. Pahuja is a practicing hospitalist, and has been closely involved with the hospitalist group he works with, plus his clients and students.

Dr. Pahuja used a few slides from his latest edition of his company’s DVD, Aerolib Physician Advisor`s Guide DVD – a coaching tool for physician advisors, case managers, and anyone else who needs to work with documentation for medical necessity – and he went over examples of the impact on a real world hospitalist group that he is familiar with in his work.

Replay and Handouts

This week’s handouts include:

Transmittals 505, 534, 540, 541 [PDF]
CMS Acute Hospital Payment System Handout [PDF]
Dr. Salvatore’s Transmittal 534 Presentation [PPT]
Dr. Salvatore’s Transmittal 534 Slides [PDF]
Dr. Hirsch’s History of Related Claim Transmittals [PDF]
Dr. Pahuja’s Reimbursment Risk for Hospitalists [PDF]
Complete Slide deck for the show slides [PDF]
Costs v. Charges graphic [PDF]

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