Non-compliant Payers: “Hello, CMS, Are You Listening?”

Dr. Ronald HirschMay 2, 2023

As you may know, several payers have adopted a policy that they will review hospital billing for facility fees for emergency department visits, and will use their proprietary tools to automatically downgrade such visit codes based on the diagnoses and services listed on the claim. But as nearly all surely know, this is not compliant activity.


Centers for Medicare & Medicaid Services (CMS) guidance is that hospitals should develop their own guidelines on choosing a facility code and sticking by it. It does not say that payers can arbitrarily adjust the codes. Of course, they are free to request the medical record and a copy of the hospital coding guidelines and audit the claim, but that is clearly not the same as a computer algorithm automatically downgrading the claim.


Read the full article here


Programming note: Listen every Monday as Dr. Ronald Hirsch makes his Monday Rounds on Monitor Mondays with Chuck Buck, 10 Eastern and sponsored by R1 Physician Advisory Solutions.

Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.