It’s another day with a few stories to report.
First up, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently fined an inpatient rehabilitation facility (IRF) in Louisiana $1.2 million for inappropriate admissions to their facility. But that is not what was unusual with this case. What stood out to me is that not only was the facility fined, but the rehab physician who reviewed and approved the admissions and provided ongoing care was also fined $575,000.
Now, granted, I have not read every single OIG report, but this is the first time I recall seeing a physician charged with making improper admission decisions. The report does note that the physician reportedly put improper pressure on patients to be admitted, so a penalty seems justified. It should also be noted that this was a whistleblower case, with two staff members of the facility earning a 20-percent reward. This case makes me wonder how the OIG would view a physician who admits inpatients to the hospital knowing that the two-midnight rule was not met, but was encouraged to liberally use inpatient status or to count delays in care as necessary days. Will a utilization review (UR) nurse be the next whistleblower getting a very nice payout?
Moving on, I have talked recently about ED visit downgrades done by payers when their proprietary tools come up with a different visit level than the facility or doctor billed. One such tool is the UnitedHealthcare (UHC) Emergency Department Claim (EDC) analyzer, and we know that UHC sells access to this tool to both payers and hospitals to use. Last week I heard a totally unsubstantiated rumor that the version of the tool they sell to payors is different than that which is sold to hospitals. If your hospital uses this tool to designate your ED facility fees, watch your claims closely. If payers are using the same tool, but still downgrading your visits, then something very nefarious may be going on.
Some of you know that Leapfrog Group released their hospital safety grades a couple of weeks ago. If you did well, I am sure your people are screaming it from the rooftops. But let me tell you about one hospital in Chicago. Roseland Community Hospital was the only hospital in the city to receive a grade of F. But here is the catch. Roseland Community received a B rating from the Lown Institute, which does not just look at a few select measures, but also at each hospital’s social responsibility, community benefit, equity, and inclusivity. Looking at the whole picture can sometimes provide a better measure of a hospital’s true quality of care.
Speaking of community benefit, last week I was in Monument Health Rapid City Hospital in South Dakota. During my talk, we discussed the Centers for Medicare & Medicaid Services (CMS) proposal to make the codes for homelessness a complication or comorbidity (CC) in 2024. Here is the thing, though: it’s easy to report the social determinants, but much harder to address them.
But Monument Health has a social worker, Hailey Twietmeyer, who is all-in on both. She goes out into her community, finds the resources patients may need, and establishes partnerships. You can tell from her passion that she loves what she does.
Every hospital needs a Hailey.
Programming note: Listen to Dr. Ronald Hirsch every Monday as he makes his rounds during Monitor Monday and sponsored by R1-RCM.
Today is election day. I wanted to talk about the process by which laws are passed and regulations created in healthcare. Recently, the fall of
As the November elections neared, you might have expected Washington to slow to a crawl amidst campaigning and uncertainty about the future. However, the show
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Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
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This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
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