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Medicare audits

Rajiv Sharma, Sarah Tinkler, Arnab Mitra, Sudeshna Pal, Raven Susu-Mago, Miron Stano
Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients...
September 24, 2017: Health Economics
Megan Elliott-Rudder, Catherine Harding, Joseph McGirr, Alexa Seal, Louis Pilotto
BACKGROUND: Despite available Medicare Benefits Schedule subsidies, it has been suggested that screening and treatment for osteoporosis are under-accessed in Australia, particularly in patients ≥70 years. This study describes the rate of osteoporosis treatment in those aged ≥70 years in regional New South Wales as identified in the electronic medical records (EMR) of 11 general practices. METHODS: EMR data were extracted using a Canning Tool adaptation. The prevalence of osteoporosis, fracture and bone-active medication prescriptions were described, and associations examined...
2017: Australian Family Physician
John R Griffith
Hospitals contracting with the Centers for Medicare & Medicaid Services (CMS) must comply with Conditions of Participation (CoP), enforced by 4 certified independent accrediting organizations (AOs) or individual state survey. Recent work documents that the system fails to achieve consistent clinical outcomes, allowing several-fold variation in mortality and patient safety. Other publicly reported evidence shows weaker clinical performance by state-surveyed hospitals, inexplicable variation in individual state surveys, and recurring disagreement between initial and audit surveyors...
May 1, 2017: American Journal of Medical Quality: the Official Journal of the American College of Medical Quality
Ann M Sheehy, Jeannine Z Engel, Charles F S Locke, Daniel J Weissburg, Kevin Eldridge, Bartho Caponi, Amy Deutschendorf
Hospitalists and other providers must classify hospitalized patients as inpatient or outpatient, the latter of which includes all observation stays. These orders direct hospital billing and payment, as well as patient out-of-pocket expenses. The Centers for Medicare & Medicaid Services (CMS) audits hospital billing for Medicare beneficiaries, historically through the Recovery Audit program. A recent U.S. Government Accountability Office (GAO) report identified problems in the hospital appeals process of Recovery Audit program audits to which CMS proposed reforms...
April 2017: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
(no author information available yet)
This final rule addresses the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments under section 1923(g)(1)(A) of the Social Security Act (Act), and the application of such limitation in the annual DSH audits required under section 1923(j) of the Act, by clarifying that the hospital-specific DSH limit is based only on uncompensated care costs. Specifically, this rule makes explicit in the text of the regulation, an existing interpretation that uncompensated care costs include only those costs for Medicaid eligible individuals that remain after accounting for payments made to hospitals by or on behalf of Medicaid eligible individuals, including Medicare and other third party payments that compensate the hospitals for care furnished to such individuals...
April 3, 2017: Federal Register
Rachel Dolin, Laura C Hanson, Sarah F Rosenblum, Sally C Stearns, George M Holmes, Pam Silberman
CONTEXT: The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients...
June 2017: Journal of Pain and Symptom Management
Heike Schütze, Lisa Jackson Pulver, Mark Harris
BACKGROUND: Indigenous peoples experience worse health and die at younger ages than their non-indigenous counterparts. Ethnicity data enables health services to identify inequalities experienced by minority populations and to implement and monitor services specifically targeting them. Despite significant Government intervention, Australia's Indigenous peoples, the Aboriginal and Torres Strait Islander peoples, continue to be under identified in data sets. We explored the barriers to Indigenous status identification in urban general practice in two areas in Sydney...
January 31, 2017: BMC Health Services Research
Donald P Frush
Radiation and potential risk during medical imaging is one of the foremost issues for the imaging community. Because of this, there are growing demands for accountability, including appropriate use of ionizing radiation in diagnostic and image-guided procedures. Factors contributing to this include increasing use of medical imaging; increased scrutiny (from awareness to alarm) by patients/caregivers and the public over radiation risk; and mounting calls for accountability from regulatory, accrediting, healthcare coverage (e...
February 2017: Health Physics
Timothy I Morgenthaler, Vilmarie Rodriguez
BACKGROUND: Although effective methods for venous thromboembolism prophylaxis (VTE-P) have been known for decades, reliable implementation has been challenging. OBJECTIVE: Develop reliable VTE-P systems for adult and for pediatric patients to reduce preventable venous thromboembolism (VTE). DESIGN: We used a discovery and diffusion system to first develop an effective system in 1 hospital location, and then spread the principle best practices across the entire 22-hospital system...
December 2016: Journal of Hospital Medicine: An Official Publication of the Society of Hospital Medicine
James P Lisik, Michelle M Dowsey, Joshua Petterwood, Peter F M Choong
BACKGROUND: Arthroscopic knee surgery has been a topic of significant controversy in recent orthopaedic literature. Multiple studies have used administrative (Victorian Admitted Episodes Dataset and Centre for Health Record Linkage) data to identify trends in practice. This study explored the usage and reporting of arthroscopic knee surgery by conducting a detailed audit at a major Victorian public hospital. METHODS: A database of orthopaedic procedures at St Vincent's Hospital Melbourne was used to retrospectively identify cases of knee arthroscopy from 1 December 2011 to 1 April 2014...
May 2017: ANZ Journal of Surgery
Heike Schütze, Lisa Jackson Pulver, Mark Harris
BACKGROUND: The Medicare-rebated Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item number 715) has been progressively implemented across Australia since 1999. OBJECTIVE: This paper explores some of the reasons why the uptake of Health Assessment for Aboriginal and Torres Strait Islander People remains low in some metropolitan general practices. METHODS: Semi-structured interviews and self-complete mail surveys with 31 general practice staff and practitioners were combined with an audit of practice systems and patient medical records in seven general practices in Sydney...
June 2016: Australian Family Physician
Affan Umer, David S Shapiro, Chris Hughes, Cynthia Ross-Richardson, Scott Ellner
BACKGROUND: Catheter-associated urinary tract infections (CAUTI) have been associated with increases in morbidity and mortality as well as increased costs of hospitalization. At our institution, we implemented a protocol for indwelling catheter use, maintenance, and removal based on Center for Medicare and Medicaid Services (CMS) guidelines, in efforts to reduce CAUTI rates. METHODS: A hospital committee of quality stewards focused on several measures which included staff education, modification of existing systems to ensure compliance, and auditing of patient care areas for catheter utilization before implementation of the protocol...
April 2016: Connecticut Medicine
Natasha H Dolgin, Babak Movahedi, Paulo N A Martins, Robert Goldberg, Kate L Lapane, Frederick A Anderson, Adel Bozorgzadeh
BACKGROUND: The central tenet of liver transplant organ allocation is to prioritize the sickest patients first. However, a 2007 Centers for Medicare and Medicaid Services regulatory policy, Conditions of Participation (COP), which mandates publically reported transplant center performance assessment and outcomes-based auditing, critically altered waitlist management and clinical decision making. We examine the extent to which COP implementation is associated with increased removal of the "sickest" patients from the liver transplant waitlist...
June 2016: Journal of the American College of Surgeons
(no author information available yet)
CMS has made changes in the scope of work for the Recovery Auditor program and has proposed a number of other changes to be implemented when new RA contracts are issued. CMS has restricted the number of additional documentation requests, has shortened the "look-back" period for patient status reviews, and announced penalties for RAs with high error rates. The new contracts shorten the time RAs have to complete complex reviews, requires RAs to wait 30 days before referring cases to the Medicare Administrative Contractors, and postpones contingency payments to RAs until after the second level of appeals...
March 2016: Hospital Case Management: the Monthly Update on Hospital-based Care Planning and Critical Paths
(no author information available yet)
The Centers for Medicare & Medicaid Services (CMS) is continuing to tweak its various audit programs, and the changes make it imperative that case managers stay current so they can educate the rest of the staff. Hospitals have got to get patient status right up front, and that means case managers should review every patient who comes in from every point of access. Hospitals should eliminate the silos within their various departments and outside the hospital walls with post-acute providers so everyone can work together for better patient care...
March 2016: Hospital Case Management: the Monthly Update on Hospital-based Care Planning and Critical Paths
Jeffrey H Silber, Paul R Rosenbaum, Richard N Ross, Justin M Ludwig, Wei Wang, Bijan A Niknam, Alexander S Hill, Orit Even-Shoshan, Rachel R Kelz, Lee A Fleisher
OBJECTIVE: To develop a method to allow a hospital to compare its performance using its entire patient population to the outcomes of very similar patients treated elsewhere. DATA SOURCES/SETTING: Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006. STUDY DESIGN: Using two example "focal" hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals...
December 2016: Health Services Research
Neville M Bilimoria
No abstract text is available yet for this article.
November 2015: Journal of Medical Practice Management: MPM
L N Woincham, E Kruger, M Tennant
UNLABELLED: Population prevalence of orofacial clefts (OFCs) is well documented but the service utilisation patterns of these patients have received limited consideration. OBJECTIVE: To analyse 10-year trends in the utilisation of subsidised OFC related services in Australia. DESIGN: Retrospective audit of service utilisation and claims datasets. METHODS: Using state-wide hospital admission data, all persons treated for Cleft Palate Only (CPO) and Cleft Lip Only (CLO) as their primary diagnosis from 1999 to 2009 in Western Australia were included in the data frameset...
December 2015: Community Dental Health
Sarah Kurusz
No abstract text is available yet for this article.
November 2015: Bulletin of the American College of Surgeons
Laura J Chavez, Chuan-Fen Liu, Nathan Tefft, Paul L Hebert, Brendan J Clark, Anna D Rubinsky, Gwen T Lapham, Katharine A Bradley
BACKGROUND: Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits. METHODS: Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009-10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized...
January 1, 2016: Drug and Alcohol Dependence
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