Expert review questions CMS ICD appropriateness scrutiny

on April 2, 2012  |  Permalink

Topics: Medicare, Reimbursement, Finance, Electrophysiology, Cardiovascular, Service Lines, Clinical Research, Utilization Review, Payer Relations

Eric Bushlow

After a New York suburban hospital was audited for inappropriate implantable cardioverter-defibrillator (ICD) procedures based on Medicare national coverage determination (NCD) requirements, a subsequent review found only 15% of procedures deemed questionable lacked a reasonable explanation.  Researchers performing the review argue that updates in clinical literature do not match NCD regulations, indicating some of these inappropriate exams have clinically justifiable reasons. 

Within their review, Steinberg and Mittal highlight the inherent disconnect in practicing evidence-based medicine within the context of significant regulatory oversight.  As the evidence base evolves and influences the way physicians practice medicine, regulators can be slow in integrating this new information when evaluating appropriateness. To combat this, the study’s authors suggest more detailed documentation may provide some safeguard against future scrutiny of this kind.
 

Continue reading:
Expert review questions CMS ICD appropriateness scrutiny

CMS clarifies, then delays, prepayment review demonstration

Brian Maher on January 11, 2012  |  Permalink

Topics: Cardiovascular, Service Lines, Appropriateness, Quality, Performance Improvement, Evidence-Based Practice, Methodologies, Accountable Care, Market Trends, Strategy, Payer and Regulatory Policy, Utilization Review, Payer Relations, Reimbursement, Finance, RAC and Other Post-Payment Audits, Revenue Cycle

Several weeks ago, the Centers for Medicare and Medicaid Services (CMS) announced the scheduled January 1, 2012 launch of the Recovery Audit Prepayment Review demonstration project to improve payment accuracy for select inpatient services.  The project is designed to conduct prepayment reviews to ensure medical necessity is documented and services are justified before receipt of payment for services rendered.

Although CMS recently clarified its policy by outlining the DRGs under consideration and timelines for implementation, the agency has now delayed implementation of the project altogether amid significant controversy and questions regarding the project’s scope and structure.

Continue reading:
CMS clarifies, then delays, prepayment review demonstration

CMS doubles down on appropriateness with new prepayment review demonstration

Brian Maher on December 5, 2011  |  Permalink

Topics: Cardiovascular, Service Lines, Appropriateness, Quality, Performance Improvement, Evidence-Based Practice, Methodologies, Medicare, Reimbursement, Finance, Utilization Review, Payer Relations, RAC and Other Post-Payment Audits, Revenue Cycle, Accountable Care, Market Trends, Strategy, Payer and Regulatory Policy

Building upon the success of the Medicare Recovery Audit Contractors (RACs) in recouping improper payments for potentially unnecessary health care services, CMS recently announced the “Recovery Audit Prepayment Review” demonstration to conduct prepayment reviews of certain health care services to ensure medical necessity before providers are reimbursed.

Continue reading:
CMS doubles down on appropriateness with new prepayment review demonstration