Jeff Fox’s Post

The Centers for Medicare and Medicaid Services (CMS) is signaling a shift towards heightened enforcement under the Sunshine Act in 2024. Recent updates to the Open Payments FAQs to add audit procedures and an increase in enforcement activities suggest more audits may be on the horizon.   Is your organization prepared? Learn the new FAQs, factors that might increase your chances of being audited, and proactive steps to take to prepare for a Sunshine Act audit.

looming - (of an event) seemingly about to happen and regarded as ominous or worrying Looming audits of reporting entities under the Sunshine Act! After over a decade of inactivity, the Centers for Medicare & Medicaid Services (CMS) have signaled that audits may soon commence. Stay tuned for updates on this potentially vexing development. #SunshineAct #CMS #healthcare #audits

Final Prior Authorization Rules Look to Streamline the Process, but Issues Remain: This brief examines the final CMS regulations governing prior authorization in Medicare Advantage, Marketplace, Medicaid, and other plans, how they might address some current consumer concerns, and some issues that remain. #medicaid #mdrp #financial

In recent months, the HHS Office of Inspector General (OIG) audited four Medicare Advantage (MA) plans, revealing significant overpayments tied to inaccurate diagnosis codes. These codes determine how much the Centers for Medicare & Medicaid Services (CMS) reimburses MA plans, with allegations of upcoding—where plans make patients appear sicker—leading to overpayment concerns. EmblemHealth was found to have received $130 million in overpayments for 2015, but due to CMS’s restriction on collecting pre-2018 extrapolated overpayments, only $551,917 was requested. Humana was found to have overbilled by $13.1 million between 2017-2018, with $6.8 million requested in repayment. Aetna HealthAssurance Pennsylvania Inc was asked to return $4.2 million in overpayments for 2017-2018. MMM Healthcare, LLC, a Puerto Rican subsidiary of Elevance Health, was found to have received $59 million in overpayments for 2017, though only $165,312 was requested. Each insurer has contested OIG’s findings and methodologies. Humana is currently challenging CMS’s stricter auditing standards in court. Our RCM team can assist healthcare entities by developing protocols to manage Medicare Advantage overpayment audits and recoupments. This includes ensuring accurate coding, conducting internal audits to identify discrepancies, and implementing corrective measures. We also help establish a clear response plan for addressing recoupment requests efficiently and compliantly. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

Medicare Advantage plans have long used observation status to save costs by keeping patients classified as "in observation" rather than "inpatient," shifting more costs onto patients. Despite new federal regulations meant to ensure equal coverage for both MA and traditional Medicare beneficiaries, the observation rates for MA plans remain high. In late 2023, MA plans’ observation rates fluctuated from 18.1% to 20.2%, dropping slightly from 14.4% to 16.1% in early 2024, while traditional Medicare rates held steady between 3.7% and 5.2%. Now that CMS is cracking down on this tactic, we're seeing some plans redirect similar strategies to the private side. Read more from Kodiak Solutions: https://lnkd.in/eDuqkxQK 

Incomplete patient records can cause big problems. Not only does it make it hard for doctors to provide the best care, but it also leads to financial losses. The Centers for Medicare and Medicaid Services (CMS) plan to get back about $428.4 million for just 2018, and expect even more in the future because of record-keeping mistakes. Let's make sure our patient records are complete and correct to avoid these issues and provide better care. #Healthcare #MedicalDocumentation #PatientCare

The significant financial strain faced by healthcare organizations due to Medicare Advantage (MA) plan denials underscores the urgent need for intervention.   Premier Inc.'s survey findings reveal that providers spent nearly $20 billion in 2022 alone pursuing delays and denials across payer types, with private plans imposing substantially higher costs. With approximately 15% of claims initially denied, and an average of $43.84 spent per claim, hospitals grapple with significant administrative burdens.   Our RCM team plays a pivotal role in alleviating this burden. By leveraging our expertise in revenue cycle management, we assist healthcare organizations in navigating the complex landscape of claims denials.   Through comprehensive analysis and strategic interventions, we identify opportunities to streamline denial management processes, reduce administrative costs, and improve revenue capture.   From implementing robust denial prevention strategies to facilitating efficient appeals processes, we work closely with hospitals to optimize financial performance and ensure timely reimbursement. Our proactive approach empowers healthcare organizations to mitigate the adverse impact of denials on their financial viability and enhance patient care delivery.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Fierce Healthcare

A recent HHS Office of Inspector General audit identified three key weaknesses in Centers for Medicare & Medicaid Services program safeguards against improper payments for short #inpatient stays: lack of adequate information to identify at-risk stays for noncompliance with the #twomidnightrule, absence of prepayment edits, and insufficient policies for reviewing and recovering overpayments. Over reliance on post-payment reviews by BFCC-QIOs only addresses a minimal fraction (0.6%) of the estimated $7.8 billion in improper payments and limits CMS's ability to effectively prevent and detect noncompliance. According to OIG, CMS risks continuing inability to effectively mitigate and recover #improperpayments, and recommends more robust controls and procedures.

I sure HOPE they stop using “predictability” on patient lives! “Senate report slams Medicare Advantage insurers for using predictive technology to deny claims” https://lnkd.in/gMWDZt5v We are humans ~ not cars! We are humans ~ not gambling! We are HUMANS - not a computer game! CVS Health UnitedHealth Group Humana - WE ARE HUMANS! Do better! Centers for Medicare & Medicaid Services I sure HOPE YOU “SLAM” these #medicareadvantage groups! #frm #patientadvocacy #patientaccess #seniorcare #revenuecyclemanagement #marketaccess #medicare #preauthorizations (Article published 10/21/24)