Last week the Centers for Medicare & Medicaid Services (CMS) released a blog post from agency Administrator Seema Verma titled “Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork.” In the post, Ms. Verma talked about the Recovery Audit Contractor (RAC) changes CMS made back in 2015, including implementing an accuracy rate target of 95 percent, a maximum overturn rate of 10 percent, and the new lower additional documentation request (ADR) limits. She also noted that in the fiscal year 2018, the RACs were successful, recovering $73 million (which, by the way, is a drop in the bucket compared to the $2.4 billion recouped in 2014).
But here is the problem: this post came completely out of the blue. Why did Ms. Verma feel compelled to discuss this now? The information is not new. The RACs have been operating under their current statement of work for the last three years; they have reportedly been approved to audit 133 different issues, including 59 physician issues. In addition, the RACs are permitted to audit for diagnosis-related group (DRG) validation. So what inspired this?
Having touted the RACs in this fashion, it begs the question of whether it heralds some looming change. Is CMS planning to raise the ADR limit? Will CMS open the RACs up to short stays? Who really knows, except, perhaps, CMS. Yet, we did see a notice on the RAC web page reading that “CMS may require the RACs to review claims based on referrals from the OIG (Office of Inspector General) or Department of Justice, or the Unified Program Integrity Contractors (UPICs). These CMS-required RAC reviews are conducted outside of the established ADR limits.”
So maybe CMS is now going to use the RACs for criminal investigations? This couldn’t possibly lead to anything good for providers.
Then there’s another disturbing bit of recent news, these involving docs, and drugs.
Last week, the makers of Exparel, an injectable anesthetic agent used for pain management after surgery, reported a 22 percent increase in sales since January.
January just happened to be when CMS and other insurers started paying extra for this medication in ambulatory surgery centers (ASCs) to try to reduce opioid use. So if this drug is so good, why wasn’t it used before in ASCs? Because the doctors own the ASCs, and using a costly drug that is not directly reimbursed means fewer profits for them. Now that the cost was reimbursed, the use increased greatly.
Why didn’t CMS also start to pay extra if the drug is used after surgery in a hospital? Because doctors, as we understand, already use it whenever it is needed since it has no effect on their payment for the procedure.
Is incentivizing providers like this a good thing? Time will tell.
The Centers for Medicare & Medicaid Services (CMS) continues to expand its focus on hospital readmissions in the FY 2027 IPPS (Inpatient Prospective Payment System)
With the April 1 update, the Centers for Medicare and Medicaid Services (CMS) implemented 80 new PCS codes. To break it down, there are 24
Please log in to your account to comment on this article.
Breast biopsy procedures may be clinically straightforward but accurately translating them into compliant billing can be anything but. In this focused webcast, Shawn Blackburn, CPC, CPMA, CIC, CRC, CCS-P breaks down how imaging guidance, lesion count, laterality, and payer expectations all impact how these procedures should be reported. Through clear explanations and real-world scenarios, you’ll gain practical insight into aligning clinical workflows with billing requirements, avoiding common pitfalls, and ensuring your documentation supports accurate reimbursement and compliance.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Sherri L. Clayton, RHIT, CSS. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
BLOOM INTO SAVINGS! Get 25% OFF during our spring sale through March 27. Use code SPRING26 at checkout to claim this offer.
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
