The decision to admit to inpatient or to place in observation is a medical necessity matter. On the American Case Management Association (ACMA) Learning Link,
It is crucial to understand the differentiation between a denial for lack of medical necessity and a denial for incorrect status. Last week marked the
The Medicare IPO list was doomed years ago. For readers of and listeners to RACmonitor and Monitor Mondays, overthinking things is what we do. It’s
Sometimes, in an audit, it comes down to the definition of “medical necessity.” While the coronavirus pandemic is horrible already, it seems to be getting
Opdivo is an immunotherapy treatment for advanced cancer. What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is
Some providers are experiencing high-volume denials based on idiosyncratic edits, made-up rules, and black-box edits. I have lost count of the number of publications released
Documentation is essential in order to avoid RAC problems. On the Sept. 9 edition of Monitor Mondays, Dr. John K. Hall made an excellent presentation
The ruling focused on key hospice admissions. A recent RACmonitor article focused on the AseraCare case, wherein the 11th Circuit Court of Appeals concluded that
Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual
There are steps providers should take for holding managed care plans accountable. Considerable effort is regularly devoted by healthcare providers to overcome coverage denials through
Don’t confuse your payer policy with providers’ medical degrees My recent article regarding secondary diagnosis coding and my advice to “just follow the guidelines” seems to
Bad advice tends to circulate regarding how to select the correct E&M codes. At a recent oncology conference in California, the speaker before me
Medicare regulations are complex and even seasoned professionals struggle to apply them consistently. Due to overwhelming demand, Dr. Hirsch returns for Part 2 of Ask Dr. Hirsch: Clarifying Medicare’s Most Misunderstood Rules to answer even more of Medicare’s most misunderstood questions, covering inpatient status, observation, SNF access, Medicare Advantage denials, and more. Join Dr. Hirsch as he provides clear, referenced answers to real-world questions submitted by your peers, helping you navigate Medicare compliance with confidence and clarity.
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.
Artificial intelligence is rapidly transforming healthcare revenue cycle operations, from coding and auditing to compliance and denials. Join industry leaders Pam Warren (MaineHealth) and Raemarie Jimenez (AAPC) for a live fireside chat exploring how AI is changing workflows, workforce roles, payer-provider dynamics, and compliance risk—and what organizations should be doing now to prepare.
Prepare for FY 2027 IPPS changes with a comprehensive 3-part masterclass covering ICD-10-CM/PCS updates, MS-DRG shifts, NTAPs, compliance risks, and reimbursement strategies.
Stay ahead of FY 2027 reimbursement changes with expert analysis of MS-DRG shifts, NTAP updates, Medicare Code Edits, and emerging technologies impacting inpatient payment accuracy.
Stay ahead of FY 2027 ICD-10-PCS changes with expert analysis of new procedure codes, revised guidelines, and high-impact updates affecting reimbursement, compliance, and inpatient coding accuracy.
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