HealthDataInsights (HDI) posted one new issue in one category to its CMS list for providers in Region D. (See link for individual state applicability.)
This week’s updates include revisions to State Operations Manual (SOM), Appendix A -Survey Protocol, Regulations and Interpretive Guidelines for Hospitals; Claim Status Category and Claim Status Codes update; and more!
As the year rolls to a close and you start to look forward to 2016, it's time to step back, look at your program, and set some goals for next year. Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, Massachusetts, says it's always a good idea for case managers to stick to tried and true best practices that have been proven effective over time.
Identify the new audit process that will be used by one of the two quality improvement organizations in charge of short stays under the 2-midnight rule.
The utilization review (UR) process is a required process to determine if the care a physician provides the patient is medically necessary and reimbursable by the payer source. While the exact definition of medical necessity varies amongst insurers and government agencies, section 1862 (a)(1)(a) of the Social Security Act provides the basic groundwork, stating, "Notwithstanding any other provisions of this tile, no payment may be made … for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."
