Government Affairs Committee – Member Articles
MA and the Two-Midnight Rule: What’s Wrong with this Picture?
January 24, 2024 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Well, we are only three weeks into the year, so three weeks into the applicability of the Two-Midnight Rule to Medicare Advantage (MA) plans, but...
2024 Deductibles, Coinsurances and Copayments – Know the Numbers
January 16, 2024 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Since we are a few days into 2024, and every Medicare patient’s yearly deductible resets, it is an opportune time to review a few payment...
LTACHs and MA Plans – Understanding Why The Rules Are Different
January 10, 2024 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
In a recent final rule, CMS-4201-F, the Centers for Medicare & Medicaid Services (CMS) went to great lengths to specify that Medicare Advantage (MA) plans...
CMS Proposes New Appeal Process – Complexity is High, but Impact is Low
January 3, 2024 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
EDITOR’S NOTE: Listen to Dr. Ronald Hirsch as he makes his Monday Rounds on Monitor Mondays, this coming Monday, Jan. 8 at 10 a.m. EST...
Adversaries and Partners – Can a Payer be Both?
December 6, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Ok, I will admit that I am a glass-half-empty guy. I would love to always see the positives in things, but someone has to be...
Preoperative Testing: Dogma or Dilemma
November 29, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
As many of you know, most patients having surgery must undergo a preoperative evaluation by the facility at which the surgery will be performed. Depending...
Saving Lives by Discharging Patients – and a QIO Skirting the Rules
November 15, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
We often talk about length of stay, and you all should know by now that I absolutely hate when the Medicare geometric mean length of...
United Healthcare’s Medicare Advantage and the Two-Midnight Rule
November 8, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Well, I suppose I have given you enough of a break from my writing about Medicare Advantage (MA) plans and the Two-Midnight Rule. Last week,...
NCDs, LCDs, Discharge Planning, and Home Care – All in One Article
November 1, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
My topic list has been overflowing with information lately, so it’s time for another rapid-fire article. First up, a few weeks ago the Centers for...
CMS Says Post-Acute Care Choice Only Goes So Far
October 25, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Access to post-acute care remains an issue in most hospitals around the country. Exacerbated by the staffing challenges that worsened during COVID-19, the ability to...
More DRG Reductions Coming? Opening an Artery Creates an Opening for Auditors
October 18, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Tired of me talking about the Medicare Advantage (MA) plans? Me too, so in this article I am not going to mention them. So, let’s...
The Crux of Criteria: Adhering to Standards of Care
October 11, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Have you heard enough from us yet about the new Centers for Medicare & Medicaid Services (CMS) rule requiring Medicare Advantage (MA) plans to follow...
Transfers and Medicare Payment – Who Knew it Could Be So Complex?
October 4, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Let me start this article by wishing a belated happy birthday to the Two-Midnight Rule. Yes, 10 years ago Sunday, on Oct. 1, 2013, the...
Medicare Advantage and the Two-Midnight Rule
September 27, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
There has been a lot of recent chatter about the applicability of the Two-Midnight Rule to Medicare Advantage (MA) plans. If ever there was rampant...
CMS Tells Livanta to Reassess Short-Stay Memo
September 20, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Well, I went and did it. You have been hearing me talk over the past few weeks about the now-infamous Livanta memo, in which they...
Discrimination Against the Disabled? Not on CMS’s Watch
September 13, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Today I have two small things and then a really big thing to cover. First up, LinCare, a home oxygen supplier, was fined $29 million...
Why Are Patient Appeals More Common Than Expected?
September 6, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
As required by their Statement of Work, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for regions 2, 3, 5, 7, and 9,...
$3.50 or $10,800,000? How Much Does a Service Actually Cost?
August 30, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Many of us eagerly, or with dread, await the yearly payment system rules that the Centers for Medicare & Medicaid Services (CMS) releases. Keeping up...
CMS Sends Up Warning Flare on Discharge Planning
August 23, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Back in June, the Centers for Medicare & Medicaid Services (CMS) released a memo titled “Requirements for Hospital Discharges to Post-Acute Care Providers,” which was...
Livanta Memo Highlight of Healthcare News Week
August 16, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
The news cycle never seems to rest. First, a bill has been introduced in Congress to once again try to get observation days to count...
Important: Livanta Confirms Stance on One Day Inpatient Admissions
August 9, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
As I reported last week for RACmonitor, Livanta released a newsletter about short inpatient stays at the end of July. Their case examples were, to...
Malnutrition and Inpatient Admission – Two Updates
August 2, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Today’s first topic is an update to something I reported about on Monitor Mondays back in 2017: a U.S. Department of Health and Human Services...
MOON Review a Week after the New Moon – on Monday
July 26, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
I have to admit, I am still upset at David Glaser for hiding the fact that last week was a new moon – and using...
Refusing to Tolerate Patient Violence
July 19, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Let me start today with some sad news many of you may have caught wind of last week. A Tennessee orthopedic surgeon was shot dead...
Plenty of Healthcare News to Cover as Summer Heats Up
July 12, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
There has been lots of healthcare news in the past two weeks. First, I hope all of you read my RACmonitor e-news article from July...
The Right Observation Rate – I Have the Numbers, Sort of…
July 5, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
If you have heard me speak or have read my articles you know that one of the questions most asked is “what is the target/benchmark/right...
Readmissions: Understanding the Complex Finances and the Hidden Nuances
June 28, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Readmissions are a common topic of concern around hospitals and rightly so, but the issue is much more complex than it seems. First, of course we all want to reduce readmissions. In fact, don’t we all want to reduce every single hospital admission? Wouldn’t it be great if no one ever needed hospital care? But for now, that’s not a realistic goal. On the other hand, addressing readmissions is realistic.
Case Managers Don’t Demand Discharges – And They Also Face Moral Distress While Working to Solve the Problem
June 21, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Last week the New York Times published an article titled “The Moral Crisis of America’s Doctors” with a subheading stating, “the corporatization of healthcare has...
All Healed Up with Nowhere to Go
June 14, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
On the June 5 edition of Monitor Mondays and in a recent RACmonitor news article, Dr. Bonny Olney from R1 RCM spoke about those patients...
Understanding the PEPPER: “My Patients are Sicker than Everyone Else’s Patients”
June 2, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
We have all heard it, time and time again. In fact, I recall telling my hospital’s chief medical officer that my patients were sicker than...
Inpatient Rehabilitation Admissions Go Under the Microscope…in One State
May 24, 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
With little fanfare, last week the Centers for Medicare & Medicaid Services (CMS) announced another Review Choice Demonstration Project. Joining the ongoing Review Choice Demonstration...
Breaking News: Medicare Advantage Must Follow Two-Midnight Rule
April 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
With an extremely compressed timeframe, the Centers for Medicare & Medicaid Services (CMS) released CMS-4201-F, the rule setting new regulations for Medicare Advantage (MA) plans. In December 2020, CMS proposed to codify the requirement that MA plans follow the Two-Midnight Rule, including the Inpatient-Only List. Only a few weeks after the comment period closed, during which 887 comments were submitted, CMS sent the final rule to the Office of Management and Budget (OMB) for approval on March 8; approval was issued on March 31, and the final rule was released April 5.
Getting on Board - the Problem with ED Boarding
February 2023 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Understanding precisely what the phenomenon of “ED boarding” means is vital to managing proper placement of patients.
An Observation about Observation Rates (and Other Notes)
November 2022 | Ronald Hirsch, MD, FACP, CHRI | RACMonitor.com
Benchmark rates for observation depend on understanding your numerator and denominator.
Imagine
June 2022 | Deb K. Banerjee, MD, FACP, MBA/HCM
Imagine you were in a perfect world of healthcare delivery. No restrictions for your hospital, physicians, nursing homes, investigations or site of surgery. No cap on home health agencies, or the type of medication to take. No silo between mental and physical health, no restrictions to choose your own physician, or a health aide.
Developing an Effective IP Hip and Knee Joint Program
May 2022
Just because anterior hips and routine total knee replacements are no longer on the IPO / MIO list does NOT mean that many of those patients cannot be statused as IP when appropriate.
Condition Code 44 and its Compliant Execution
April 2022 | Maria Johar, MD
92 year old independent lady who lives alone in a rural area is brought in by her granddaughter, who is a nurse, for persistent tachycardia and disorientation with difficulty following commands. She has persistent alteration in mental status, a heart rate of 160- 190 which has remained elevated in the ED. ECG in the ED is interpreted as possible WPW syndrome.
Medicare Advantage Star Ratings... What Are They? Why Should We Care? What Can We Do About Them?
February 2022 | Nicholas Libertin III, MD
The Centers for Medicare & Medicaid Services (CMS) created a Star Rating system to help beneficiaries and their families compare plan performance and quality for Medicare Advantage plans. The plans are rated on a one-to-five scale, with one star representing “poor performance” and five stars representing “excellent performance”. Medicare Advantage Star Ratings are released ...
Court: Patients Must Be Able to Appeal Status Change from Inpatient to Observation
January 2021 | Nina Youngstrom
With comments to CMS due by 9/13/2021, ACPA Board of Directors member and Clinical Documentation Integrity Co-Chair Dr. Erica Remer urges everyone to review the 2022 Physician Fee Schedule Proposed Rule - in particular, the portion about split/shared billing with the professional fee - in this ICD10Monitor.com article...
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