News from the Week of January 27 2014

SPECIAL ALERT FOR TODAY’S NEWS…

CMS Delays Audits of Claims under the Two-Midnight Rule 

Auditors must wait even longer. Notice, though... he still has the files?

Auditors must wait even longer. Notice, though… he still has the files?

PLEASE NOTICE – They have not delayed enforcement nor enactment of the rule, ONLY any significant audit activity by CMS contractors.

CMS has delayed the two-midnight rule through Sept. 30 after fierce opposition came from hospitals, physicians and other healthcare groups. According to a CMS update, the enforcement of the two-midnight rule will not begin until this October. This means Medicare administrative contractors and recovery auditors will not conduct two-midnight post-payment reviews of claims with admissions dates between Oct. 1, 2013, and Oct. 1, 2014. However, MACs and RAC will carry out prepayment reviews of hospital admissions that occur between March 31, 2014, and Sept. 30, 2014. Depending on the hospital, auditors will review 10 to 25 claims per facility.

According to a CMS update, the enforcement of the two-midnight rule will not begin until this October. This means Medicare administrative contractors and recovery auditors will not conduct two-midnight post-payment reviews of claims with admissions dates between Oct. 1, 2013, and Oct. 1, 2014. However, MACs and RAC will carry out prepayment reviews of hospital admissions that occur between March 31, 2014, and Sept. 30, 2014. Depending on the hospital, auditors will review 10 to 25 claims per facility.

Credits: CMS Delays Two-Midnight Rule

AHA STATEMENT ON EXTENSION OF TWO MIDNIGHT ENFORCEMENT MORATORIUM

I Dare You Not to Yawn

I Dare You Not to Yawn

Here’s what they had to say, which I find fault with… <sigh>

“We are pleased that CMS has extended its enforcement moratorium on the two-midnight policy for an additional six months, as the AHA has urged.”

I fault them for calling this a moratorium on enforcement. Oh, it will still be enforced, just not audited, until AFTER Oct 1, 2014.

Read the whole statement at their site:

 Credits: AHA Statement on Extension of Two Midnight Enforcement Moratorium

Now… About Last Week…

Are We Moving to More and More Outpatient Billing?

It’s been pondered aloud by many, lately, if CMS is not moving to reduce costs by forcing the increased use of outpatient services. If you consider this for a moment, you can see that it is one of the very few opportunities that exist for reducing at least the pace of rising healthcare costs if not the actual costs and/or charges.

See this post at Stop The Leakage blog: What Does the Growth in Outpatient Volumes Mean for Population Health?

Would this growth in OP be so bad? Perhaps I haven’t mentioned this in the blog before, but if we want to keep costs down, the way to do it is to reduce Length of Stay (LOS) — this would have the same effect as reducing “inventory” in a manufacturing plant, which is a well-known method of reducing costs.

There is also an inherent advantage to a hospital that reduces LOS — it could provide a competitive edge. I can’t spend time here discussing that, but people in marketing would understand this. How does it translate to a hospital? It does, it just takes a different tack than a manufacturer. But back to my point… more OP should mean lower costs, overall, for everyone concerned.

Yes, I know… several readers (I can probably name you) will be thinking, “That’s outrageous! We deserve Inpatient payment for XYZ, and ABC and lots of things!” I don’t doubt that certain things are certainly deserving of higher payments, but then… isn’t that why there is this thing called the Inpatient-Only Procedure List?

What are you more interested in:  do you want to argue about the dollars involved so you can prove you are “right” even though you have to wait 3 years to get paid? – or do you want to get paid NOW and move on, treat more patients, and not wonder at what point your hospital will go belly up?

Me, I’d like to get paid and move on. Am I just giving up, not fighting CMS on what’s the right about to be paid? No, I’m merely being practical: get paid first; argue later. Besides, you aren’t in control, right, wrong or indifferent.

I keep hearing stories of appeals at the ALJ level being won… for a claim worth $300.  What? Why are we even THERE for $300? We’ve already lost money just DOING the appeal.

It’s time to stop appealing everything. Besides, the system is flooded and broken beyond repair. That situation will NOT end up well for the providers.

Write that off, move forward. FIX THE BILLS BEFORE THEY GO OUT THE DOOR.

I have some ideas about that, coming up soon…

RAC Backlogs Ain’t Going Away…

With over 15,000 appeals being submitted weekly, the system is WAY beyond capacity. A recent Modern Healthcare article, “RAC Appeals Backlog Cause for Frustration,” cited OMHA’s letter notifying hospitals that the existing backlog could take two years or more to clear up…

Credits: RAC Backlogs

But They’re Saving Money Elsewhere, So Where Is It?

Perhaps CGI was involved in the ACOs, too?

Perhaps CGI was involved in the ACOs, too?

It ain’t going to OMHA, now is it?

CMS claims that Medicare and Pioneer ACOs saved $380M in 2012, by this wonderful new payment system. But of course, they still can’t seem to fund OMHA.

Here’s a quote from the article:

 “Our experience has shown that ACOs can increase quality while lowering costs. As a result of the programs we’ve initiated, our patients have experienced better access to their primary care physician, higher quality measures, and fewer trips to the hospital,” said Kenneth W. Wilkins, M.D. president of Coastal Carolina Health Care, an advanced payment ACO.

And this helps us… how?  Show me the money!

Credits: CMS: Medicare and Pioneer ACOs saved $380M

6 Ways to Avoid Unintentional Medicare Fraud

Healthcare fraud has long been considered to be billing for treatment you did not provide. However, that definition has changed lately and both hospitals and physicians should now understand how good intentions will not necessarily keep them out of trouble.

From the article: “Physicians have to be mindful that mismanagement or sloppy business practices can land them in a lot of hot water because prosecutors are looking for other manner of fraud besides making up a patient name or billing for someone who never really came to your office.”

As infuriating as it may be, THAT is why the Obama Administration continues to say, publically, that providers are committing lots of “fraud.”

Give the article a read… interesting insights…

Credits: 6 Ways to Avoid Unintentional Medicare Fraud

 

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