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November 23, 2015

Recent Stories

From Report on Medicare Compliance - In a curveball for hospitals, the HHS Office of Inspector General (OIG) is extending the scope of overpayment findings in Medicare compliance reviews beyond the usual three years. As a result, relatively modest overpayments have recently ballooned into million-dollar overpayments, and not just from the familiar extrapolation of errors. OIG acknowledges it lacks the authority to go outside the three-year recovery period, but suggests hospitals work with CMS to repay the money because of their obligations under the 60-day Medicare overpayment refund mandate. Read more

Although Congress put a nail in the coffin of new off-campus provider-based… Read more

Recovery audits are moving ahead on two fronts, now that CMS has… Read more

Coding audits are due for a retread because of the sheer volume… Read more

From the Editor

Welcome to your Report on Medicare Compliance subscriber-only Web page

Be sure to visit often, for PDFs of issues, archives of articles, links to government documents and more!

Please e-mail me with your comments on the last issue of Report on Medicare Compliance, story ideas for future issues, or any other suggestions you have that can make the newsletter more useful for you.

November 23, 2015
OIG Finds Nearly $800K in Overpayments to Sierra View Medical Center

In a new Medicare compliance review of Sierra View Medical Center, OIG discovered a $798,000 overpayment.

November 20, 2015
University of Florida Shells Out $20M to Settle Charges of Improper Billing

DOJ says University of Florida will pay $19.875M to settle allegations it improperly charged salaries and other costs to HHS grants.

November 20, 2015
Example of Screening Cardiac Inpatient Admissions

To improve compliance with medical necessity, Elizabeth Lamkin, CEO of PACE Healthcare Consulting, suggests hospital committees develop checklists to review outpatient registrations and inpatient admissions for high-volume and/or high-cost procedures, such as ICDs, to prevent medically unnecessary services or inappropriate site of service. Here’s an example of screening cardiac inpatient admissions developed by Lamkin and colleague Pati Hildebrand, executive director of Hildebrand Healthcare Consulting:

  • Patient presents to the ED and is registered there.
  • If the patient has an ST segment elevation myocardial infarction, the ED initiates a code STEMI procedure.
  • If the physician orders an outpatient diagnostic procedure for further cardiac work-up, the ED notifies admissions/discharge/transfer (ADT)/registration and cath lab.

  • If the physician orders observation or admit to inpatient, care management (CM) reviews for medical necessity and bed status.

  • The hospital ADT registers the patient in ED and contacts CM for bed-status advice based on the physician order.

  • If CM and the physician agree, a bed is assigned. If CM doesn’t concur with the physician’s bed status order, CM asks the physician adviser to review and work with the attending physician on bed status.

  • The patient is transferred to the cardiac unit or cath lab.

  • Cath lab staff check orders and documentation again. If incomplete or incorrect, the cath lab contacts registration/ADT to correct.

  • If admission is emergent, the cath lab activates emergency procedures to notify CM and ADT for proper admission procedures.

  • The procedure is performed, and the physician documents it on the chart.

  • The patient is moved to the expected level of care: outpatient recovery, extended recovery, observation or inpatient.

  • If the patient has a complication, or his or her condition worsens and warrants a higher level of care, CM reviews for medical necessity and bed placement.

  • If the attending physician disagrees with bed placement and provides new information, CM reviews again for medical necessity and consults the physician adviser to work with the attending physician.

  • CM notifies ADT bed control of admission for bed assignment and bed status.

Contact Lamkin at

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