From Report on Medicare Compliance - Patients in the gray area of medical necessity present a regulatory, reimbursement and ethical challenge for hospitals. If patients need only custodial care, which is not covered by Medicare, hospitals are playing with fire if they submit claims for anything except ancillary services. But sometimes what seems to be a social admission is really medically necessary and it just hasn’t been documented well. Or hospitals may have other reimbursement options, including the use of an advance beneficiary notice (ABN) and the hospital-issued notice of non-coverage. Read more

From Report on Medicare Compliance - With recovery audit contractors (RACs) on light duty and Medicare administrative contractors (MACs) limited to probe-and-audit reviews under the two-midnight rule, Colleen Dailey, clinical coordinator of defense audits at WellSpan Health, is knee deep in claim denials from commercial payers. It’s a different world than Medicare, because the denials often stem from problems with preauthorizations for diagnostic tests, which are sometimes a matter of chasing down paperwork under the gun… Read more

Compliance Blog

By AIS Staff - July 15, 2014
The scandal at the Department of Veterans Affairs (VA) that has so outraged the nation over veterans’ access to medical care also has pointed the spotlight on whistleblowers and a covered entity’s compliance with whistleblower protection laws. This month’s issue of Report on Patient Privacy (RPP)...
By AIS Staff - June 16, 2014
Let’s say, for whatever reason, you wanted an electronic copy of your medical records. You have a right to them, by law, except that’s not what’s happening at many HIPAA covered entities. For its June issue, Report on Patient Privacy (RPP) took a look at the websites of several prominent health...
By Nina Youngstrom - March 10, 2014
Two recovery audit contractors have a bone to pick with some of the changes planned by CMS for the next round of the five-year RAC contracts and have filed “pre-award” protests with the Government Accountability Office (GAO), Emily Evans, a partner in Obsidian Research Group in Nashville, said at a...

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