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If you follow politics, you are well aware that there is an ongoing debate between nationalism (primarily concerned with what goes on within a country’s borders) and globalism (trying to optimize outcomes for all nations). I will not wade into this debate, but it got...
Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...
It is a truism that hospital financial outcomes result from an interdependent web of departments contributing specific functions and deliverables, commonly referred to as the revenue cycle. Each silo – admitting, managed care contracting, utilization management,...
By Jerilyn Morrissey, MD Twenty years ago, few hospitals thought of using a physician as a regular resource for utilization review purposes. My colleagues, Drs. Corrato, Zebrowitz, and McCarter introduced the Physician Advisor role to the industry in the early 2000s....
OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...
Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...
In 2013, the Centers for Medicare and Medicaid Services (CMS) finalized the “Two-Midnight” Rule addressing when beneficiary hospitalizations are appropriate for inpatient payment under Medicare Part A. CMS adopted the “Two-Midnight” Rule to simplify the beneficiary...
In 2016, the Office of the Inspector General (OIG) published a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Policy”, summarizing the first findings of hospital billing patterns since the implementation of the Two-Midnight Rule. The results surprised...
If you follow politics, you are well aware that there is an ongoing debate between nationalism (primarily concerned with what goes on within a country’s borders) and globalism (trying to optimize outcomes for all nations). I will not wade into this debate, but it got...
Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...
It is a truism that hospital financial outcomes result from an interdependent web of departments contributing specific functions and deliverables, commonly referred to as the revenue cycle. Each silo – admitting, managed care contracting, utilization management,...
By Jerilyn Morrissey, MD Twenty years ago, few hospitals thought of using a physician as a regular resource for utilization review purposes. My colleagues, Drs. Corrato, Zebrowitz, and McCarter introduced the Physician Advisor role to the industry in the early 2000s....
OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...
Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...
In 2013, the Centers for Medicare and Medicaid Services (CMS) finalized the “Two-Midnight” Rule addressing when beneficiary hospitalizations are appropriate for inpatient payment under Medicare Part A. CMS adopted the “Two-Midnight” Rule to simplify the beneficiary...
In 2016, the Office of the Inspector General (OIG) published a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Policy”, summarizing the first findings of hospital billing patterns since the implementation of the Two-Midnight Rule. The results surprised...
Overview On November 2, 2021, CMS released the anticipated CY 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule (CMS-1753-FC), finalizing this year’s Medicare payment rates for hospital outpatient...
Additional Funds, Delay in Reporting Requirements, and Audits The Provider Relief Fund (PRF) was established when Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act to support American families, workers, and healthcare providers in the...
By Jerilyn Morrissey, MD Regardless of who your team reports to on the organization chart, there is no getting around the fact that Utilization Management (UM) is part of the clinical revenue cycle of your organization. Embracing that concept may challenge your...
