Health Data Insights Begins Medical Necessity Reviews
(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) responsible for auditing health care providers in Region D, has announced it will immediately begin reviews on previously approved projects which involve the medical necessity of selected inpatient DRG payments. A complete list of the medical necessity “issues” currently being examined by HDI can be found on its Website. Scope of Responsibility: RACs, such as HDI, contract with the CMS to perform post-payment reviews of Medicare claims to find overpayments (and theoretically, underpayments in return for a percentage (from 9 percent to 12.5 ...
With ZPICs, PSCs, and RACs Fighting Most, If Not All, Extrapolation Challenges, Experienced Counsel Is Imperative if You Hope to Have the Extrapolation Invalidated
(July 20, 2010): In recent years, we have seen agents for the Centers for Medicare & Medicaid Services (CMS) increasingly rely on statistical extrapolation estimates when assessing claims overpayments. In early cases, we successfully invalidated countless extrapolations by identifying relatively basic reasons for why the calculations were inconsistent with accepted statistical principles and practices. Now, however, providers should expect for ZPICs and PSCs (and soon, RACs) to send a team of statisticians and attorneys to vigorously oppose most (if not all) hearings challenging the validity of the extrapolation calculation. Regardless of whether you are providing Partial Hospitalization, Evaluation and Management (E/M), ...
States Are Taking Aim at Home Health Providers – Florida’s MFCU Will Expand Their Review and Investigation of Home Health Providers Billing Medicaid – Your State May be Next
(July 19, 2010): Home health care providers are in the crosshairs again. On July 15, HHS granted Florida a waiver of the anti-data mining provisions of federal Medicaid program regulations that will allow its Medicaid Fraud Control Unit (MFCU) to begin seeking out reasons to investigate home health and other providers for fraud. While Florida is the first and currently the only state to obtain a waiver of this type, if Florida’s pilot program “succeeds”, the other 49 MFCUs could soon be doing the same thing. MFCU “strike forces” are designed to investigate referred cases of fraud. They are prohibited by ...
How Can You Address Deficiencies in Extrapolation Calculations? Don’t Assume Contractors’ Results Can Be Reproduced
(July 14, 2010): Imagine a ZPIC, PSC, or RAC hands you a claims analysis rife with alleged errors, an indecipherable list of statistical formulas, and an extrapolated recovery demand that will cripple your practice or clinic. What steps should you take to analyze their work? Based on our experience, providers can and should carefully assess the contractor’s actions, use of formulas and application of the RAT-STAT program when selecting a statistical sample and extrapolating the alleged damages based on the sample pulled. Over the years, we have challenged the extrapolation of damages conducted by Medicare contractors around the country, covering ...
Medicare/Medicaid News
Health Data Insights Begins Medical Necessity Reviews(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare...
States Are Taking Aim at Home Health Providers – Florida’s MFCU Will Expand Their Review and Investigation of Home Health Providers Billing Medicaid – Your State May be Next(July 19, 2010): Home health care providers are in the crosshairs again. On July...
President Obama Appoints New Head of CMS(July 12, 2010): Last week, President Obama announced the recess appointment of Dr....
Read More Posts From This CategoryExtrapolation News
With ZPICs, PSCs, and RACs Fighting Most, If Not All, Extrapolation Challenges, Experienced Counsel Is Imperative if You Hope to Have the Extrapolation Invalidated(July 20, 2010): In recent years, we have seen agents for the Centers for Medicare...
How Can You Address Deficiencies in Extrapolation Calculations? Don’t Assume Contractors’ Results Can Be Reproduced(July 14, 2010): Imagine a ZPIC, PSC, or RAC hands you a claims analysis rife with...
Can ZPICs and PSCs Review a Mere Sample of Claims and Seek Extrapolated Damages? Maybe. . .Maybe Not. . . Tips for Defending Cases Where Damages Have Been Extrapolated(July 12, 2010): A ZPIC’s use of extrapolation can be a surefire way of destroying...
Read More Posts From This CategoryCompliance
Overview of the Zone Program Integrity Contractor (ZPIC) Program(July 12, 2010): Pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS was required to use competitive measures to replace the current Medicare Fiscal Intermediaries (Part A) and Carriers (Part B) contractors with Medicare Administrative Contractors (MACs). After setting up the new MAC regions, CMS created... [Read more of this review]
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