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Welcome to the weekend and thanks for checking in.

We’re bringing you the news from the past week as well as providing you with a look at the week ahead. Looking ahead we have a preview of tomorrow’s edition of Monitor Mondays.

Looking Back this Past Week

Here you are enjoying the weekend and in so doing we’re sharing two stories that appeared in Thursday’s edition of RACmonitor e-news —two stories worth a second read. We’ve also included links to both stories so you can take a deeper dive. We’d be interested in your reaction. 

Here’s the situation, as recounted by Ronald Hirsch, MD, who was reflecting on a recent edition of Nina Youngstrom’s newsletter, Report on Medicare Compliance. Youngstrom reported that Cedars Sinai Medical Center in Los Angeles paid a nearly $900,000 civil monetary penalty for the actions of a single physician who, reportedly coded many of his or her visits using time instead of the laborious task of calculating codes based on the elements of the history, physical, and medical decision-making. Hirsch wrote that using time is allowed as long as over 50 percent of the time spent with the patient is in counseling and coordination of care. Using time to code is common in many specialties, such as oncology, for which treatment planning requires a great deal of shared decision-making between the patient and the physician, wrote Hirsch, who also advised that it should not constitute the majority of visits in any specialty. Hirsch further noted in his article that Youngstrom reported that the hospital paid back 100 percent of the professional fees collected on behalf of the physician, making, he noted, that the hospital made no effort to separate out those related to upcoding from those that were properly coded.

This refund was made as a self-disclosure, meaning the hospital found the errors and reported its findings to the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG); the errors were not found as the result of an audit performed by the OIG or any other governmental audit agency. 

Healthcare attorney David Glaser responded in his corresponding article, disclosing that he wasn’t involved in the Cedar Sinai situation.  He noted that it was possible that there were unique, compelling reasons supporting the decision to refund the entire physician payment. However, wrote Glaser, “generally speaking, one wouldn’t refund all of the payments received for a physician’s work under such a scenario. When I encounter a situation in which I believe a physician has chosen a higher code than appropriate, I recommend refunding the difference between what was billed and what we believe the service rendered was.” 

Glaser then offered some words of caution, noting that the Youngstrom article suggested that the money was refunded through the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) self-disclosure protocol. “With the exception of Stark violations, I am very hard-pressed to envision a situation in which I would recommend using the self-disclosure protocol rather than making a refund directly to the Medicare Administrative Contractor (MAC),” wrote Glaser. “Going to the OIG is admitting that you had some sort of improper intent. Remember that to impose any sort of false claims liability, the government must show that you, at a minimum, acted in “reckless disregard” of the law,” he concluded.  

Now you decide. Let us know what course of action you would take under the circumstances. 

Moving Forward

Monitor Mondays to Broadcast Live from HCCA in Las Vegas

U.S. Department of Health and Human Services (HHS) Principal Deputy Inspector General Joanne M. Chiedi will be the special guest on Monitor Mondays, which will broadcast live from the Health Care Compliance Association (HCCA) annual Compliance Institute in Las Vegas at 10 a.m. EST on Monday, April 20.

Chiedi has served as the principal HHS Deputy Inspector General  since 2003. As the highest-ranking career official in her office, she leads an organization of more than 1,600 investigators, auditiors, evaluators, lawyers, and management professionals, all of whom oversee the integrity and efficiency of the nation’s trillion-dollar investment in federal health and human services programs.

Coming Attractions

Provider-Based Under Arrangement Services, Joint Ventures and Management Contracts 

In next Thursday’s edition of RACmonitor e-news former CMS official Stanley Sokolove will file a report on the regulations governing joint ventures and management contracts under Provider-based agreements. Sokolove will explain that many hospitals have utilized the services of a third-party to provide medical services to hospital patients.  “A word to the wise,” offers Sokolove in his forthcoming article, “be careful in your decision-making regarding this type of contractual obligation.”  

C-Suite Executives Pressuring Physicians to Admit Patients 

Also in next Thursday’s edition of RACmonitor e-news Dr. Hirsch will report on a physician’s ethical and compliance dilemma. Since the two-midnight rule went into effect, the anonymous physician’s hospital has seen a drop in the number of inpatient admissions and an accompanying drop in revenue. Hirsch will report in his article that, according to the physician, the hospital’s CEO and CFO have stated that the Recovery Auditors (RAs) are not auditing records and that since the quality improvement organization (QIO) is only going to audit 10 charts every six months, they (the c-suite executives) perceive that the risk created by being generous with admission decisions is low. 

Revenue from Surgery: Learn How to Optimize Revenue Integrity Compliantly 

Thursday, April 14
1:30-2:30 PM ET
Presented by Ronald Hirsch, MD

Could revenue from surgery at your facility be at risk? Risk-prone factors surrounding surgical procedures conducted at your facility could pose serious compliance issues. Learn how to protect your facility’s revenue from surgery.

Register to Attend 

Warning: You Have 60 Days to Come Clean

Tuesday, April 26
1:30-2:30 PM ET
Presented By David Glaser, Esq.

CMS published a final rule detailing the duty of providers to report and return overpayments within 60 days of their identification. Congress adopted the “report and return” requirement as part of the Patient Protection and Affordable Care Act. Consider this to be a must-see webcast.

Register to Attend

In Production 

Creating Healthier Rural Communities

Thursday, May 12
1:30-2:30 PM ET

Rural healthcare authority Janelle Ali-Dinar, PhD, is producing a webcast for RACmonitor readers on the state of rural. The presentation will address rural precision medicine, advanced diagnostics and population health methods/services of treatment to bridge the gap of care for the most critical needs of rural populations including chronic disease management, opioid abuse and medication management and premature deaths. 

How to Win Against Auditors Who Use Dirty Tricks Against You

Wednesday, May 25
1:30-2:30 PM ET

Not all contract auditors are bad.  But some are, and they know how to manipulate hospital data to make the facility look like it cheated the federal government. Based on an auditor’s gross manipulation of a hospital’s claims data, a facility could end up owing millions of dollars based on an extrapolation from only 30 claims. In his upcoming webcast, New York attorney Edward Roche, PhD, JD, will reveal how facilities can learn the secrets behind the devious tricks used by unscrupulous contract auditors.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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