IdeaCentre HIM Solutions’ Post

When was the last time you audited your incident-to billing? One Michigan health system found out about its noncompliance the hard way: An OIG settlement of $671,310. #oig #falseclaimsact #incidentto #medicalcoding #medicalbilling #ideacentrehimsolutions Link:

I recently came across a poignant member story involving a new mom. Despite having an in-network pediatrician and full insurance coverage, the family faced unexpected $1,000+ bills for their newborn’s initial appointments. Well-visits are typically covered as part of critical #PreventiveCare under most policies. This was back in FEBRUARY. Our dedicated team worked tirelessly behind the scenes, advocating for the family and untangling the complexities. Fast forward to this week, and the member happily shared that their bill is now $0. She told her newborn and pediatrics nurse care manager she wouldn’t have had the bandwidth to resolve the issue. If you follow KFF Health News and NPR’s #BillOfTheMonth series, you know this member is not alone. Chances are, someone here in my network has encountered this same experience or has helped someone close to them navigate a similar situation. Consider sharing it here: https://lnkd.in/gwZnkapU Healthcare doesn’t have to be like this. It shouldn’t be like this. It’s why I am so proud of Included Health’s claims advocacy and specialized care teams who have helped members save an average of $1,700 each time we engaged in billing advocacy; that average jumps to $2,622 in savings for denial cases i.e. instances when a service that should be covered is not. Beyond financial savings, our members value our impact on time. By sparing them the need to sit on hold, take time away from work or family, and endure the stress of healthcare administration, we are giving back precious days and hours. On average, it takes an average of 60 days to resolve a claim. Multiply that by the millions we serve, and you'll begin to appreciate the day-to-day impact of our team. #HealthcareTransparency #HealthcareNavigation #PatientAdvocacy

In our latest alert, our lawyers summarize a recent decision from a federal district court in South Carolina that will have a marked impact on due process challenges to statistical sampling and extrapolation in the Medicare claims appeal context. Learn more here: https://ow.ly/YyVy50QOY0U #HealthCare #PolicyandRegulatory #ZeroPaidClaims

If you attended the practice management course at #ASPN2024, you heard David Daggett & me speak of the importance of ensuring any consulting or medical directorship contracts were substantiated by #fairmarket value and contracts that specifically outline the services provided in exchange for the compensation paid. This is a perfect example of how these loose arrangements can spell TROUBLE.

Buncombe County, North Carolina, has filed to join Attorney General Josh Stein's lawsuit against HCA Healthcare's Mission Health takeover, citing deteriorating emergency department (ED) wait times and the financial burden placed on its EMS crews. Despite requests to expedite care, wait times at Mission Hospital rose significantly. Buncombe County seeks over $3 million in damages, alleging that HCA failed to address these issues until after legal action was taken. This adds to the growing legal challenges against HCA, with other municipalities in North Carolina also pursuing litigation over the Mission Health acquisition. In 2022, class-action complaints were filed, accusing HCA of exploiting its monopoly power. A federal judge denied HCA's motion to dismiss the litigation in February, highlighting the ongoing legal battles over the healthcare giant's practices and acquisitions. This development highlights HCA Healthcare's alleged failure to meet quality standards post-acquisition, affecting patient care. Our team ensures patient protection by monitoring quality metrics, advocating for timely care, and supporting legal actions to hold healthcare providers accountable for maintaining standards and addressing deficiencies promptly. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Fierce Healthcare

Hot off the presses!!! The Report on Medicare Compliance just released a detailed story on the St. Peter’s Health Settlement and the Complaint filed by the DOJ against Dr. Weiner under the False Claims Act. A link is below. Tune into next week’s Stark Integrity Podcast where I will release the first of 2 Episodes covering this settlement and the learnings from this intriguing Settlement. #StarkIntegrity #NelsonMullins #AKS #FCA #CommercialReasonableness #FMV #Compliance #DOJ #RMC If you do not have a subscription to RMC use the hyperlink in my comments below as the box below will take you to the subscription site. I have permission from the RMC to share the full article.

The recent #FalseClaimsAct complaint against Erlanger Health System underscores the critical importance of #compliance and #ethicalstandards in #healthcare. It's vital that financial relationships between hospitals and physicians do not compromise the #integrity of clinical decision-making. At the heart of healthcare is the patient's well-being, and it's essential that treatment decisions are guided solely by patient needs, free from any undue financial influences. Ensuring compliance with regulations is not just about avoiding legal repercussions; it's about maintaining trust and integrity in our healthcare system. As we continue to strive for excellence in healthcare, let's commit to upholding the highest ethical standards in all our practices.

On April 16, 2024, Inspector General Christi A. Grimm testified before the United States House Committee on Energy and Commerce's Subcommittee on Oversight and Investigations. The testimony focused on how improper payments are costing taxpayers billions of dollars and weakening #Medicare and #Medicaid. A key takeaway from the session was the Department of Health and Human Services' (#HHS) more stringent approach to regulating health risk assessments, as illustrated in the graphic below.   At Porter, we are aligned with the #OIG's approach and are pioneering a new way to ensure evidence of treatment. Our exclusive Care Guide service, along with our AI-infused care coordination platform, engages members before and for 30 days after each in-home visit to ensure follow-through on all identified #gaps in care providing #evidence of treatment including:   - Appointment scheduling with providers. - Referrals to appropriate community resources. - Verification that needed follow-up care is secured. - Confirm information obtained during the assessment was submitted to the appropriate #providers. - Provide a summary to the beneficiary that includes their diagnoses, medications, scheduled follow-up #appointments, plan for #carecoordination, and contact information for community resources; and - Enroll the beneficiary in appropriate CM/DM programs.   Follow the link to learn how Porter is pioneering new ways to ensure evidence of treatment: https://lnkd.in/ez4yKahA #CMS #Healthriskassessment #medicareadvantage #carecoordination #SDOH #Riskadjustment

Imagine you just resolved a personal injury case. 💰 💰 💰 Now, how are you going to protect the claimant's future access to Medicare benefits? ⚕ "No need to, Medicare does not require LMSAs." Technically, true. But MSAs aren't required in workers' compensation settlements either and MSAs are standard operating procedure there. Why there and not part of your case? Ever asked yourself that question? 😕 Does ignoring the issue in your case provide full protection to your claimant and you if Medicare later disagrees? Are you willing to gamble on the likelihood that Medicare does not ever seek recovery for future medicals in your seven figure case? 🎲 ♠ ♥ ♦ ♣ 🃏 If you've been so careful on the case up until now, why would you be so cavalier about something so important as protecting future access to Medicare benefits? https://lnkd.in/gkDt_NhK Cattie & Gonzalez, PLLC #AHigherStandardinMSPCompliance #MSP #MedicareSecondaryPayer #Medicare #ConditionalPayments #MedicarePartA #MedicarePartB #MedicarePartC #MedicarePartD #BCRC #BenefitsCoordinationandRecoveryCenter #CRC #CommercialRepaymentCenter #MAOs #MedicareAdvantageOrganizations #PDPs #PrescriptionDrugPlans #Medicaid #Private #ERISA #MilitaryLiens #VA #Tricare #LienResolution #MCP #MedicalCostProjection #WCMSA #WorkersCompensation #MedicareSetAsides #MSAs #LMSA #LiabilityMedicareSetAsides #MSALegalOpinion

The #NoSurprisesAct protects most privately insured patients from surprise out-of-pocket balance bills, those unexpected charges that could leave you scrambling. Learn how to avoid surprise bills and fight incorrect charges: https://hubs.la/Q02qssTn0 #HealthcareAdvocacy