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Chasing KPI’s: How Department Metrics Undermine Hospitals’ Medicare Advantage Performance
If you follow politics, you are well aware that there is an ongoing debate between nationalism (primarily concerned with what goes on within a country’s borders) and globalism (trying to optimize outcomes for all nations). I will not wade into this debate, but it got...
Medicare Advantage: The New RACs
Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...
Not Hitting Your Revenue Cycle Benchmarks? Look at Utilization Management.
It is a truism that hospital financial outcomes result from an interdependent web of departments contributing specific functions and deliverables, commonly referred to as the revenue cycle. Each silo – admitting, managed care contracting, utilization management,...
The Role of the Physician Advisor in the Observation Rate Conversation
By Jerilyn Morrissey, MD Twenty years ago, few hospitals thought of using a physician as a regular resource for utilization review purposes. My colleagues, Drs. Corrato, Zebrowitz, and McCarter introduced the Physician Advisor role to the industry in the early 2000s....
Medicare Advantage or Disadvantage?
OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...
Aligning Payor-Provider UR Practices – Proceed with Caution!
Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...
You Can’t Get the Right Answer if You Don’t Ask the Right Question
In 2013, the Centers for Medicare and Medicaid Services (CMS) finalized the “Two-Midnight” Rule addressing when beneficiary hospitalizations are appropriate for inpatient payment under Medicare Part A. CMS adopted the “Two-Midnight” Rule to simplify the beneficiary...
Vulnerabilities Remain Under Medicare’s 2-Midnight Policy
In 2016, the Office of the Inspector General (OIG) published a report, “Vulnerabilities Remain Under Medicare’s 2-Midnight Policy”, summarizing the first findings of hospital billing patterns since the implementation of the Two-Midnight Rule. The results surprised...
Chasing KPI’s: How Department Metrics Undermine Hospitals’ Medicare Advantage Performance
Medicare Advantage: The New RACs
Not Hitting Your Revenue Cycle Benchmarks? Look at Utilization Management.
The Role of the Physician Advisor in the Observation Rate Conversation
Medicare Advantage or Disadvantage?
Aligning Payor-Provider UR Practices – Proceed with Caution!
You Can’t Get the Right Answer if You Don’t Ask the Right Question
