Are institutions appealing sepsis denials if the patient meets sepsis-2/super systemic inflammatory response syndrome (SIRS) criteria, but not sequential organ failure assessment (SOFA) criteria? We have one hospital in our system that uses only sepsis-2 as their criteria, and many of them have...Read More »
A Humana health plan in Florida overcharged Medicare by nearly $200 million in 2015 by incorrectly billing for high severity hierarchical condition categories (HCC) that were not supported, according to...Read More »
I was wondering if anyone had experience with denials from commercial payers that goes beyond the third level of appeals. We are getting response letters that state “completion of a level 3 dispute exhausts internal administrative rights.” What are other hospital systems doing with this response...Read More »
Sunrise Hospital & Medical Center in Winchester, Nevada, submitted Medicare claims for rehabilitative services that did not comply with Medicare billing requirements,...Read More »
Findings from an Office of Inspector General (OIG) audit show that Blue Cross Blue Shield (BCBS) of Michigan submitted claims with high-risk ICD-10-CM codes that did not comply with federal requirements, resulting in at least $14...Read More »
A report from the Office of Inspector General (OIG) shows that Medicare billing for high-level inpatient stays increased over a six-year period, sparking concerns by the government about...Read More »
Between mid-2017 and pre-pandemic 2019, 774 hospitals have been penalized by the federal government for having high rates of patients with possibly avoidable medical complications, according to a hospital penalty “look-up” system by...Read More »
