07/21/2025

Recent RAC Monitor Article

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More Prior Authorizations Coming – And Correcting Errors
Today I want to provide some clarifications to a couple of things I recently read. Now, I must say that correcting others is often viewed negatively, but it is important. The rapid spread of misinformation in our day and age is ubiquitous, and it does not take long for one person’s opinion to become considered the absolute truth.

You may have read last week’s RACmonitor article from David Glaser wherein he discussed “incident to” services. As he pointed out, the actual federal regulation allows “incident to” to be used for established patients with new problems, yet some thought leaders and even the Medicare contractors, for some reason, claim that it is not allowed for these new problems. So, which is right?

Well, I have to think that the federal regulation is the definitive source of truth, no matter how many Internet sources claim otherwise. Now, since the audits are conducted by the same Medicare contractors who are used as a source for the false statement, you may have a battle ahead to fight a denial, but a good lawyer and a federal judge should know that not everything you read on the Internet is true.

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Unpacking the RUC Time Study: Where Physician Work Valuation Meets Compliance Risk
Healthcare reimbursement operates on a fascinating paradox: physician services aren’t paid based on market rates or simple invoices, but on calculated values derived from estimated work, practice costs, and liability.

This system, the Resource-Based Relative Value Scale (RBRVS), depends critically on one contested input: physician time.

The RBRVS Update Committee (RUC), an advisory group organized by the American Medical Association (AMA), sits at the heart of this process. The RUC recommends how much physician work should be assigned to specific CPT® codes, but its methodology – particularly its reliance on physician-reported time surveys – has sparked ongoing debate among researchers, regulators, and industry observers.

For compliance professionals, this isn’t academic discourse. It translates directly into coding accuracy questions, documentation standards, audit vulnerabilities, and potential financial exposure.

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Abe Sutton and MA Reform
From think tanks to federal agencies, health policy in the U.S. is often shaped by voices we don’t always see in the headlines. Abe Sutton, a key figure in the Trump Administration’s Medicare Advantage (MA) reform efforts, is one of them. Let’s take a look at who he is and what he believes to be the key to improving MA.

Sutton currently serves as Director of the Center for Medicare and Medicaid Innovation (CMMI), which is responsible for testing and rolling out new ways to change how care is delivered and how healthcare dollars are spent. He’s also one of several members of the Trump Administration that have previously served at the Paragon Health Institute, a conservative policy think tank.

So, what does this actually mean for healthcare in practice?

Abe Sutton isn’t new to the topics that the Centers for Medicare & Medicaid Services (CMS) governs. Before his current role, he co-authored a piece in Health Affairs on Medicare Advantage (MA), a program that now covers more than half of the eligible Medicare population using what is called risk adjustment. One of his biggest concerns?

Overpayments!

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More Prior Authorizations Coming – And Correcting Errors
Today I want to provide some clarifications to a couple of things I recently read. Now, I must say that correcting others is often viewed negatively, but it is important. The rapid spread of misinformation in our day and age is ubiquitous, and it does not take long for one person’s opinion to become considered the absolute truth.

You may have read last week’s RACmonitor article from David Glaser wherein he discussed “incident to” services. As he pointed out, the actual federal regulation allows “incident to” to be used for established patients with new problems, yet some thought leaders and even the Medicare contractors, for some reason, claim that it is not allowed for these new problems. So, which is right?

Well, I have to think that the federal regulation is the definitive source of truth, no matter how many Internet sources claim otherwise. Now, since the audits are conducted by the same Medicare contractors who are used as a source for the false statement, you may have a battle ahead to fight a denial, but a good lawyer and a federal judge should know that not everything you read on the Internet is true.

READ MORE 

Navigating Conflicting Guidance on Incident-to Services
Sorting through strident but contradictory opinions can be challenging. Last week, I explained why many new problems for an established patient can be treated as incident-to, notwithstanding what the Medicare Administrative Contractors (MACs) claim.

There is a well-known consultant who strongly disagrees, and whose scorn for my position is quite evident in a lengthy post. Because it is so common to have differing opinions in a highly regulated area, I want to take this time to examine how you can determine who to trust.

The consultant’s critique of my position opens with “this is a topic I know inside and out,” and mention of his experience, as well as his relationship with the Centers for Medicare & Medicaid Services (CMS). But neither the length of time someone has practiced, nor who they know, is evidence of quality analysis. I have been practicing for 33 years, but I would never assert that this makes my answers more accurate. In fact, at times it may make me less reliable, because I might mistakenly assume I know something without verifying it. 

When you are trying to figure out who is right, credentials and bragging are irrelevant. Only one thing matters: the text. Actually, two things: the text and whether that text is authoritative. The consultant points to a variety of statements from Novitas and Noridian that do say that a physician must see a patient who has a new problem. The consultant is 100-percent right about that. I acknowledged this last week.

I am asking whether the contractors are correct. To answer, we have to look at the regulation, because regulations are binding unless they contradict a statute or the Constitution. As a quick reminder, the regulation says that the services can be “in the course of diagnosis or treatment of an illness or injury.” The consultant says that the regulation “implies that the service must relate to a diagnosis and treatment plan initiated by the physician.” 

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