Journal of AHIMA: Appeals, Denials, HIM and Utilization Review - A Winning Combination

Dr. Ronald HirschAugust 23, 2021

Many claim that people in the United States have access to the best healthcare in the world. And while that is easily refuted with data from multiple sources, there is no question that the United States has one of the most complex healthcare delivery systems in the world. The combination of public ...

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RACMonitor: New Drug Makes a Splash – A Swan Dive or a Belly Flop?

Dr. Ronald HirschJune 17, 2021

The soaring cost of new medications and technologies is not news. Insulin was first patented in 1923, but due to incremental changes in the molecule and delivery system, a vial of insulin can still cost hundreds of dollars. When highly active antiretroviral therapy was approved for treatment of HIV in the mid-1990s, the drug combination was ...

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RAC Monitor: Rebilling Non-Medicare Inpatient Claims

Dr. Ronald HirschMarch 26, 2021

It is crucial to understand the differentiation between a denial for lack of medical necessity and a denial for incorrect status.

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RACMonitor: Deconstructing the Concept of Condition Code 44

Dr. Juliet Ugarte HopkinsMarch 3, 2021

Dear Readers,

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COSMOS: Readmission Penalties May Be Worth Swallowing For Revenue

Nina YoungstromFebruary 9, 2021

Hospitals may want to reconsider how hard they work to stave off certain Medicare readmissions because the penalties from the Hospital Readmissions Reduction Program pale compared to the loss of revenue and potential harm to patients who should be back in the hospital, a physician advisor said. That calculation may not apply to Medicare ...

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Moving Past Revenue Cycle Recovery to Achieve Financial Resilience

Nicole ShinglerFebruary 8, 2021

After a fairly predictable start, 2020’s unforeseen turn into a yearlong (and counting) pandemic created a torrent of financial and clinical challenges for hospitals and health systems. Reduced volume, increasing care complexities and an uncertain economy still remain in 2021 as hospitals continue working toward financial recovery. It won’t be ...

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RAC Monitor: Medicare Inpatient Pricer Now Available

Dr. Ronald HirschFebruary 3, 2021

When I teach Medicare regulations to physician advisors, case managers, and utilization review professionals, it is always interesting to see the reactions when I explain how Medicare calculates how much to pay for an inpatient admission. Most are aware of the Medicare Severity Diagnosis-Related Group (DRG) system and the DRG triads and dyads, and ...

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RACmonitor: One-Day Medicare Inpatient Surgery Admissions

Dr. Ronald HirschDecember 18, 2020

The CMS proposal to eliminate the Inpatient-Only List, does not mean that all procedures are to be performed as outpatient. On Jan. 18, 2018, RACmonitor published my article titled “CMS Says OK to Admit Total Knee Replacements as Inpatient.” The title created a bit of an uproar, as many thought I was conveying the message that all total knee ...

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RACmonitor: CMS Accepts Waivers for At-Home Services

Dr. Ronald HirschDecember 3, 2020

During a short Thanksgiving work week, the Centers for Medicare & Medicaid Services (CMS) found time to make two pretty significant announcements. The first is that they are now accepting waiver requests from hospitals to offer true at-home services. In this program, instead of admitting patients requiring hospital care to the hospital, ...

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RACmonitor: Total Knee Replacement Added to PEPPER

Dr. Ronald HirschDecember 1, 2020

In the midst of a pandemic, the Centers for Medicare & Medicaid Services (CMS) has decided the time is right to add a new element to the quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER). This new target area will report the percentage of total knee arthroplasties that were done under inpatient status.

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