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When the Medicare Administrative Contractors (MACs) conduct probe and educate prepayment audits of compliance with the two-midnight rule, inadequate documentation and lack of one or more of the components of certification are major reasons for the denials, according to Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm.
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A bill signed into law on April 1 directs the Centers for Medicare & Medicaid Services (CMS) to postpone post-payment audits of the two-midnight rule until after March 31, 2015. In the meantime, CMS has implemented pre-payment probe and educate reviews to determine if hospitals are in compliance.
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After St. Rose Hospital in Hayward, CA, started its readmission reduction program, the community hospitals 30-day readmission rate for all diagnoses dropped by 37% and the 90-day readmission rate declined by 43%.
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The Centers for Medicare & Medicaid Services (CMS) has announced a pause in the Recovery Auditor program while it develops new contracts with the auditors, and so the auditors can complete all claims reviews before the current contracts expire.
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Implementation of ICD-10 has been postponed until Oct. 1, 2015, and all claims submitted after that point must use the new coding system.
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Prior to the advent of the inpatient prospective payment system (IPPS), the discharge planning process was simpler and slower. Patients generally stayed in the hospital until they were well and then went home.
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Case managers have been an integral part of the discharge planning process for decades. Typically this process has involved an in-depth assessment of the patient, which has included their clinical as well as psychosocial, financial and living situations
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The Centers for Medicare & Medicaid Services Probe and Educate initiative to determine hospitals compliance with the two-midnight rule makes it clear that case managers must review physician documentation as well as medical necessity.
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Case managers should know their patients insurance benefits and out-of-pocket expenses when they develop a discharge plan to make sure the patient can afford the plan they are putting in place.
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As outbreaks continue to be reported due to unsafe injection practices and improper use of medication vials, the Centers for Medicare & Medicaid Services (CMS) is telling its surveyors to contact public health departments immediately if they see such flagrant breaches of infection control.