Monitor Mondays

Purging the Surge of Data Miners: A New FCA Program from DOJ

Mon, 31 Aug 2026 11:00:00 -0400

There has been a noticeable recent surge of activity among data-mining companies or individuals who analyze publicly available government data for potential signals of fraud, rather than the insiders who have traditionally served as relators under the federal False Claims Act (FCA).

As such, the venerable U.S. Department of Justice (DOJ) has a new process in place to mitigate the trend. It’s called Fraud Oversight through Careful Use of Statistics, (FOCUS), which will be the topic of a new report from Mary Inman, who is scheduled to be the special guest on the next edition of Monitor Mondays.
Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Gender Affirming Care (CMS-2451-F): Still Proposed

Mon, 24 Aug 2026 12:00:00 -0400

Program Update: CMS-2451-F has been published in the Federal Register. The proposed rule is effective Oct. 13, 2026. The recently posted rule prohibits federal and state Medicaid and CHIP program dollars from being spent on gender-affirming care for persons under 19 years of age.

Earlier this year, CMS-3481-P —a related proposed rule— was reported by Drew Updike, MD, a senior healthcare consultant. That rule was published in mid-December 2025.

During the next live edition of the venerable Monitor Monday Internet broadcast, Dr. Updike will share the potential impacts if this proposed rule and CMS 3481-P are both finalized.

The broadcast will also include these instantly recognizable segments:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Poyner Spruill, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Buffeted, Badgered, Bruised and Bleeding: The Battered 340B Drug Reforms

Mon, 17 Aug 2026 11:00:00 -0400

Much like the iconic TV commercials in which the late newscaster John Cameron Swayze would demonstrate on live television how the venerable Timex wristwatch could withstand relentless beatings and “could keep on ticking,” the venerable federal drug program, 340B, continues in its role to provide expensive drugs at discounted prices to the nation’s safety-net hospitals.

Due to recent legislation introduced in Congress to make comprehensive changes to the federal 340B drug pricing program, the producers of RACmonitor have invited attorney Jeff Davis with the law firm of Bass, Berry & Sim, to summarize key provisions, the potential impact of the legislation on 340B providers and the likelihood of enactment.

The broadcast will also include these instantly recognizable segments:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Poyner Spruill, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Latest Privacy Issue: AI-Powered Wearables

Mon, 10 Aug 2026 12:00:00 -0400

You wear a smartwatch as do so many other Americans. In fact, AI is transforming wearable healthcare devices from simple fitness trackers into powerful tools that collect, analyze, and share health information in real time.

During the next live edition of the long-running Monitor Monday Internet broadcast, special guest Ray Ribble will take a deep dive into AI-powered wearables and explain what you and your team must do to remain compliant.

The broadcast will also include these instantly recognizable segments:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

The One Note Samba: DOJ Data Sharing

Mon, 03 Aug 2026 11:00:00 -0400

The Department of Justice (DOJ) recently announced “data sharing” agreements with the Centers for Medicare & Medicaid Services (CMS), the Department of Homeland Security (DHS) and the Federal Trade Commission (FTC). Many believe this latest development might be the most consequential enforcement shift in twenty years. DOJ can now run analytics directly against CMS claims data, DHS travel records, and FTC complaint data, all in one shared environment.

During the next live edition of the venerable Monitor Monday Internet broadcast, senior healthcare analyst Frank Cohen, program’s special guest, says it’s the data sharing agreement has changed everything. Register now to listen and learn when Cohen explains why the idea of a defensible pattern just got a lot bigger. It’s important that you need to know what this means for your data.

The broadcast will also include these instantly recognizable segments:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Healthcare Today: Status Quo Bias

Mon, 27 Jul 2026 11:00:00 -0400

Maybe it’s the summer doldrums that keep otherwise rational people from taking a chance—especially when better alternatives may be available. But according to physician and attorney Dr. John K. Hall, the special guest on the next live edition of Monitor Mondays, some individuals prefer to maintain the status quo rather than pursue a potentially better approach. Case in point: Aetna’s recent discharge policy. Beyond the policy itself, which seems to be causing consternation among some hospitals, are there other examples? Listen to the special broadcast Monday, July 27, at 10:00 a.m. EST.

The broadcast will also include these instantly recognizable segments:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

The Latest Compliance Trap: Medicare Cost Reports

Mon, 20 Jul 2026 13:00:00 -0400

Who would have thought that the otherwise fairly simple Medicare Cost Report could be a serious compliance trap?

Some are calling the new Medicare report worksheet a possible precursor to the most significant reimbursement change in decades.

For 2026, the Centers for Medicare & Medicaid Services (CMS) will require hospitals to report Medicare Advantage (MA)-negotiated reimbursement by Medicare Severity Diagnosis-Related Group (MS-DRG).

The implications extend far beyond compliance, requiring coordination across reimbursement, finance, revenue cycle, managed care, coding, IT, and analytics.

Listen and learn during the next edition of Monitor Mondays when the CEO for Panacea Healthcare, Kevin Chmura, unpacks Worksheet S-12. You’ll quickly discover the finer details of the looming fundamental shift toward market-based reimbursement, and how forward-thinking hospitals can turn this change into a strategic advantage.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

Preventing Denials: The Role of Facility-Based Clinical Definitions

Mon, 13 Jul 2026 12:00:00 -0400

Payer-driven clinical validation is a common reason given by payers to remove ICD-10-CM/PCS diagnosis and procedure codes affecting reimbursement or quality-based payment models (e.g., the Centers for Medicare & Medicaid Services/CMS Hospital-Acquired Conditions), even though these codes are based on the documentation of licensed providers.

During the next Internet broadcast of the venerable Monitor Monday, Dr. James S. Kennedy of CDIMD will propose a strategy that engages payers in how patient conditions or treatments should be defined, diagnosed, and documented, elevating the practice of medicine and confronting denials that are often based on misinterpretations of current clinical literature.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Behavioral Health: Avoiding Common Pitfalls

Mon, 06 Jul 2026 12:00:00 -0400

Behavioral health services continue to face heightened payer scrutiny. The result: inaccurate documentation, coding, and compliance issues.

Panacea Healthcare recently hosted a webinar that focused on three high-risk areas: relative to Behavioral Health–telehealth, psychotherapy with evaluation and management (E&M) services, and the Collaborative Care Model (CoCM).

Special guest George Kelly is expected to summarize these issues while outlining the common compliance pitfalls, documentation requirements, coding best practices, and audit risks associated with each service.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, legislative affairs analyst for Zelis, will report on current healthcare legislation.

Avoiding the Next Claim Denial

Mon, 29 Jun 2026 12:00:00 -0400

There’s a method by which providers can avoid the snare of the latest claim denial strategy to garner attention. Much has been written about the Aetna policy for its “severity inpatient payment” element.

Yet almost daily, providers appear to be turning to trusted sources to avoid pitfalls. And that is why the producers of RACmonitor’s Monitor Mondays have invited physician and attorney Dr. John K. Hall to serve as special guest during the next edition of the venerable weekly national podcast.

During this remarkable live Internet broadcast, Dr. Hall will unpack the issues that seem to flummox payers, resulting in a variety of actions, ranging from recoupment to reimbursement at lower levels (i.e. “observation” rates).

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

Seeking Compliance Across the Revenue Cycle

Mon, 22 Jun 2026 11:00:00 -0400

Motivated by the notion that healthcare providers are seeking compliance solutions across the revenue cycle, the producers of Monitor Mondays have invited the CEO of Panacea Healthcare Solutions to serve as the special guest during the next upcoming broadcast.

Introducing Kevin Chmura. For more than 25 years, Mr. Chmura has been at the forefront of major healthcare vendors as they, in turn, have worked to help their clients achieve success in revenue cycle compliance.
Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

Who will Blink First? 340B Health at Center Stage as Controversy Continues

Mon, 15 Jun 2026 12:00:00 -0400

Maureen Testoni, the stalwart president and CEO of the renowned 340B Health Program, will join the long-running Monitor Mondays to

discuss Eli Lilly’s escalating demands for hospitals to submit in-house claims data as a condition of receiving 340B drug discounts.

Who will blink first?

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Folana Houston, legislative affairs analyst for Zelis, will report on current healthcare legislation.

Recent Lawsuit: Racial Concordance in Healthcare Takes Center Stage

Mon, 08 Jun 2026 13:00:00 -0400

At the heart of a recent lawsuit filed by a physician is whether the medical profession’s understanding and practice of racial concordance is legally defensible.

“Find-A-Black-Doctor” has served as a platform for Black, Indigenous, and Persons of Color (BIPOC) to locate providers who can offer them the best holistic treatment.

However, some see this as discrimination against white-majority physicians, curtailing their access to potential patients.

During my next live edition of Monitor Monday, Dr. Drew Updike, ] review the evidence behind concordance – as it pertains to women’s health, BIPOC patients, and others – to provide you your team with an appreciation of its relevance in modern medicine.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

AI and Auditing: Major Compliance Risks

Mon, 01 Jun 2026 11:00:00 -0400

It’s that bright new shiny object few seem to manage to resist: artificial intelligence (AI).

Here at RACmonitor and Monitor Mondays, we have been reporting on how this disruptive technology has been altering the compliance landscape.

And we will continue that reporting. AI is rapidly reshaping healthcare auditing and compliance, and as organizations move toward greater claim visibility and AI-driven review processes, what does that mean for audit exposure, risk, and oversight?

Join us during the next live edition of the venerable Monitor Mondays broadcast for an incredible journey, as Pam Warren explores how AI is changing the compliance landscape, and what organizations should be thinking about now. Warren, from AAPC, is the manager of regulatory billing audits for MaineHealth in Maine, the largest healthcare system in Northern New England.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Surge in False Claims Act Violations Triggers New DOJ Initiative

Mon, 18 May 2026 12:00:00 -0400

Introducing FOCUS (Fraud Oversight through Careful Use of Statistics). The U.S. Department of Justice (DOJ) has launched a new initiative in response to the surge in False Claims Act qui tam filings by data miners.

Today, roughly 45 percent of DOJ cases involve FCA data miners. You and your team will learn the inside story of this new initiative along with news of two significant data miner-initiated cases: a $6.73 million settlement against a California vascular physician who billed Medicare for unnecessary stent procedures at 30 times the national average; and a $300,000 settlement against three Illinois skilled nursing facilities that billed Medicare for unnecessary and inflated rehabilitation services.

Reporting this dramatic story will be whistleblower attorney and a partner in the New York office of Whistleblower Partners, Hamsa Mahendranathan.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

When Algorithms Audit Algorithms

Mon, 11 May 2026 11:00:00 -0400

Healthcare compliance has entered the machine-learning era, and most organizations have not yet noticed.

Providers are using artificial intelligence (AI) to generate documentation, surface reimbursable conditions, and tighten coding workflows. Regulators and payers are using AI to detect abnormal patterns, flag statistical outliers, and identify documentation that does not align with expected clinical behavior.

Both sides are operating faster than traditional human oversight can follow, according to senior healthcare analyst Frank Cohen, the special guest during the next live edition of the long-running Internet broadcast Monitor Monday, coming your way Monday, May 11 at 10 a.m. EST.

Join Cohen as he walks you and your team through a labyrinth of AI obstacles so you can avoid fines, takebacks, and penalties.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Folana Houston, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Developing Story: Updating Sepsis Terminology in ICD-10-CM

Mon, 04 May 2026 11:00:00 -0400

Documenting and coding sepsis has challenged virtually everyone in healthcare ever since Sepsis-3 redefined the condition in 2016 as a “life-threatening organ dysfunction due to a dysregulated host response to infection.”

Meanwhile, ICD-10-CM still maintains the older Sepsis-2 language of sepsis (SIRS/Systemic Inflammatory Response Syndrome due to infection, without organ dysfunction) and severe sepsis (sepsis that does result in organ dysfunction).

During the next live edition of Monitor Monday, Dr. James S. Kennedy will report on efforts currently underway to address the recent Centers for Disease Control and Protection (CDC) proposal to align ICD-10-CM to Sepsis-3/Phoenix terminology, and to introduce new codes for “impending sepsis,” also known as pre-sepsis: a morbid continuum between a localized infection with and without Sepsis-3/Phoenix-defined sepsis .

Dr. Kennedy is expected to solicit assistance from Monitor Mondays listeners toward a reasonable solution.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

SCOTUS Decision on Colorado “Conversion Therapy” Ban Leaves Much Left to Determine

Mon, 27 Apr 2026 11:00:00 -0400

The recent U.S. Supreme Court decision in Chiles v. Salazar doesn’t really close the case – but it also doesn’t really leave it open.

The 8-1 decision, in which the nation’s highest court ruled that a Colorado ban on so-called “conversion therapy” for juveniles was unconstitutional, is subtle, complex, and unnerving; the American Psychological Association issued a statement noting that it was “deeply concerned” over it.

The case relates to conversion therapy as talk therapy, specifically related to gender identity and First Amendment rights. But the decision only remands the matter for further review by the Tenth Circuit, thus leaving the issue essentially undecided.

Is this just more judicial “Calvinball” – the game highlighted in the classic comic strip Calvin and Hobbes, in which the rules are made up on the fly – or is the Court simply assuring another bite at this apple? Our own Physician and attorney Dr. John K. Hall will explore these questions and look for answers during the next edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

A Close-Up Look at Healthcare AI “Sherpas”

Mon, 20 Apr 2026 12:00:00 -0400

Artificial intelligence (AI) is clearly here to stay – it’s now an integral part of healthcare. From coding and clinical validation to payer denials and appeals, AI is often a form of power upon which decisions are made by providers, payers, and auditors.

You and your team should be aware of the several so-called healthcare “sherpas” available to interpret vast amounts of AI-generated data, among them Grok 4: an AI-powered chatbot solution developed by Elon Musk’s xAi, which is integrated with the X (formerly Twitter) social network.

As we have before, our producers invited RACmonitor Investigative Reporter Edward M. Roche to investigate AI and its sherpas, including Grok 4, during the next edition of the long-running Monitor Mondays Internet broadcast, this coming Monday, April 20, at 10 a.m. EST.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

EXCLUSIVE: Huge Loophole Has Insulated Medicare Appeals

Mon, 13 Apr 2026 11:00:00 -0400

When the U.S. Supreme Court overturned Chevron deference, it promised to restore judicial independence and limit agency overreach.

But in Medicare administrative proceedings, that promise remains unfulfilled.

Tune in to the next upcoming live edition of Monitor Mondays, when senior healthcare analyst Frank Cohen will report on his surprise when an Administrative Law Judge issued a categorical ruling: Loper Bright simply does not apply to the proceedings of the Office of Medicare Hearings and Appeals (OMHA).

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Dr. Jennifer Weinberg will be making her Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Adam Brenman will report on current healthcare legislation.

Medical Double Dose: A Paradox on Doctor’s Day

Mon, 06 Apr 2026 11:00:00 -0400

National Doctor’s Day will bring a double whammy this coming Monday when the venerable Monitor Monday continues its recognition of the occasion with a pair of featured speakers: Drs. Drew Updike and Christopher Boyle.

The day of recognition took place on March 30, the date when Eudora Brown would place flowers on the graves of late physicians, starting in 1933. Historians are quick to note that the date also commemorates the first use of anesthesia for surgery.

Fast forward to Monday, April 6, 2026: that’s when Drs. Updike and Boyle will not only be recognized for their service by Monitor Mondays, but featured as speakers.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Understanding AI Interpretation in Healthcare

Mon, 30 Mar 2026 11:00:00 -0400

Artificial intelligence (AI) is becoming part of how clinical documentation is reviewed across healthcare, from coding and clinical validation to payer denials and appeals.

In many cases, AI is influencing decisions behind the scenes, even when it is not clearly visible.

During the next live edition of the long-running Monitor Monday, the Internet broadcast produced by RACmonitor, Sharon Easterling will explain in simple terms how AI reads the clinical record.

Unlike clinicians, AI does not understand the full story of the patient. Instead, it looks for patterns such as words, phrases, and signals, and uses those patterns to reach a conclusion.

Because of this, the same record can lead to different outcomes.

Easterling, RACmonitor and Monitor Monday technology consultant, returns to the broadcast and will use a straightforward way to evaluate decisions so that conclusions remain supported, clear, and defensible, even as AI becomes more involved in the process.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney Amanda Mills will join the broadcast with his trademark segment.

· Legislative Update: Matthew Albright, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Aetna Latest to Acquiesce Amid FCA Allegations

Mon, 23 Mar 2026 11:00:00 -0400

Aetna is just the latest in a long list of healthcare entities to settle False Claims Act (FCA) allegations with a massive settlement.

The insurer, one of the nation’s largest, recently agreed to pay $117.7 million to resolve a case involving purportedly inaccurate and untruthful diagnosis codes to increase payments.

That and other recent U.S. Department of Justice (DOJ) actions will take center stage during the next edition of Monitor Mondays, when featured speakers will weigh in on striking recent trends related to such developments. Settlements and judgments under the FCA totaled $6.8 billion in the most recent full fiscal yar, an all-time record, with 84 percent of the recoveries related to matters involving the healthcare industry.

Broadcast segments will also include these instantly recognizable features:

•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

•Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

Autonomous Coding: A New Reality

Mon, 16 Mar 2026 11:00:00 -0400

Imagine machine learning and natural language processing deployed to audit claims.

Today, it’s the new reality.

Autonomous coding is dramatically altering the treacherous auditing landscape. So, how can you protect your facility from takebacks?
How do you maintain coding excellence to remain compliant?

Join this coming Monday, March 16 for the next live edition of the venerable Monitor Mondays Internet broadcast, when senior healthcare analyst Frank Cohen will describe the inner workings of autonomous coding. Cohen will also explain how to survive in today’s unforgiving audit landscape, which has become a habitat for advanced technology.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Lesson Learned: Navigating the Ever-Expanding Scope of Prior Authorization

Mon, 09 Mar 2026 11:00:00 -0400

Healthcare documentation is no longer written for a single audience. Today, the medical record must simultaneously meet federal regulatory requirements and the coverage expectations of individual payers.

While these systems often overlap, they originate from different authorities and serve different purposes. One governs compliance and program integrity; the other determines whether services are approved and reimbursed.

As prior authorization expands and audit scrutiny intensifies, hospitals are increasingly navigating both systems at once. Understanding the distinction between regulatory documentation standards and payer-driven requirements is becoming essential for aligning clinical workflows, documentation practices, and operational strategy in today’s healthcare environment.

During the next live edition of the venerable Monitor Monday, the live Internet broadcast, senior healthcare consultant Penny Jefferson returns to the broadcast to explain what many today are calling the new face of healthcare.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

CMS Launches CRUSH: A New Anti-Fraud Program

Mon, 02 Mar 2026 11:00:00 -0500

The Centers for Medicare & Medicaid Services (CMS) has launched a new initiative titled Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH).

CRUSH is a sweeping fraud prevention program. In an official news release posted Thursday, CMS reported suspending $5.7 billion in suspected fraudulent Medicare payments, preventing $1.5 billion in DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) billing, revoking more than 5,500 providers’ billing privileges, and denying 122,000 claims that failed medical necessity checks.

This latest news, including a nationwide DMEPOS enrollment moratorium and a $259.5 million Medicaid funding deferral, signals a decisive shift toward real-time enforcement.

What does CRUSH mean for providers, revenue cycle leaders, and compliance teams?

Senior healthcare consultant Penny Jefferson will be the special guest during the next live edition of the long-running news and information national podcast Monitor Mondays. Jefferson, the director of clinical documentation integrity (CDI) services for the University of California Davis Medical Center, will report on this new and developing story.

The broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Medicare Advantage and Prior Authorizations: The Good. The Bad. The Ugly.

Mon, 23 Feb 2026 12:00:00 -0500

Prior authorizations among Medicare Advantage plans have drawn criticism and concern from patients, providers, lawmakers, and regulators. But hospitals and doctors are uniquely positioned to advocate for their patients’ access to and coverage for care. What’s necessary is the need to understand the rules of the process. And Medicare Advantage plans have many of them.

During the next live edition of the venerable Monitor Monday, the Internet broadcast, Richelle Marting, a healthcare attorney, and certified coder, will help you understand when and how Medicare Advantage plans can use prior authorizations for the critical protections you need to know to advocate for patient care.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright of Zelis, will report on current healthcare legislation.

Did CMS Draw the Right Conclusion about Aetna’s Severity Policy?

Mon, 16 Feb 2026 11:00:00 -0500

In a January 28 article, Dr. Ronald Hirsch verified that the Centers for Medicare and Medicaid Services (CMS) “has no problem” with the Aetna Severity Payment policy because it “meets the Two-Midnight Rule.”

However, there is more to consider than compliance with 42 CFR 412.3.

Federal regulations also state Medicare Advantage organizations must comply with Traditional Medicare laws including payment criteria for inpatient admissions at 42 CFR 422.101(b)(2). So the burning question remains: Is CMS disregarding pertinent regulations that could nullify Aetna’s policy?

During the next live edition of the venerable Monitor Monday, the Internet broadcast, Cheryl Ericson, senior director of clinical policy and education for the Brundage Group, will address this apparent contradiction.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Reign of Terror: Special Audit Report

Mon, 09 Feb 2026 12:00:00 -0500

It’s raining RACs.

The Recovery Auditor Contractors (RACs), together with an alphabet soup of other private and public auditors, are coming down hard on hospitals and physician practices, looking for omissions and errors in submitted claims.

Then there are seemingly contradictory rules from the Centers for Medicare & Medicaid Services (CMS).

It’s little wonder that providers are treading cautiously as they look to thread the needle of compliance.

This coming Monday, the venerable Monitor Mondays broadcast will present a cadre of the sharpest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – just here.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

Docs Take Another Financial Hit

Mon, 02 Feb 2026 15:00:00 -0500

There was a time when Relative Value Units (RVUs) felt like a stable currency – something you and others could take to the bank.

That was then. This is now.

Then, productivity could be measured, compensation plans could be managed, and economic models could assume relative stability in physician work measurement.

Recently, actions by the Centers for Medicare & Medicaid Services (CMS) – culminating in the 2026 Physician Fee Schedule – signal a philosophical shift in how physician work is valued, adjusted, and used as a policy lever. The takeaway is not that RVUs are broken; it is that they are no longer designed to be static.

For more details on this change, the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to be the special guest during the next live edition of the venerated Internet broadcast, coming up on Monday, Feb. 2.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

$556 million False Claims Settlement Rattles Many in Healthcare

Mon, 26 Jan 2026 13:00:00 -0500

While many of you were enjoying the holidays, Kaiser Permanente was
back in the news. This time, another whistleblower case which resulted in
an amazing $556 million settlement to resolve allegations that the giant
provider/payer fudged on its Medicare Advantage risk adjustment.

Reporting the lead story during the next live edition of Monitor Mondays will
be Liz Soltan, a New York-based senior associate at Whistleblower
Partners. Soltan is a member of the firm's litigation team who represented
Dr. James Taylor in his landmark False Claims Act (FCA) case against
Kaiser Permanente which resolved allegations of Medicare Advantage risk
adjustment fraud. Soltan also works on a major Medicare Advantage risk
adjustment fraud case against UnitedHealth Group on behalf of
whistleblower Benjamin Poehling.

Broadcast segments will also include these instantly recognizable features:

 Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM,
will be making his Monday Rounds.

 The RAC Report: Healthcare attorney Knicole Emanuel, partner
at the law firm of Nelson Mullins, will report the latest news about
auditors.

 Risky Business: Healthcare attorney David Glaser, shareholder
in the law offices of Fredrikson & Byron, will join the broadcast with
his trademark segment.

 Legislative Update: Adam Brenman, legislative affairs liaison for
Zelis, will report on current healthcare legislation.

CMS Blocks Gender Affirmative Care

Mon, 12 Jan 2026 12:00:00 -0500

The Centers for Medicare & Medicaid Services (CMS) will block hospitals from performing certain interventions that are intended to change a child’s physical appearance to align an asserted sex identity.

Reporting the lead story during the next live edition of Monitor Mondays will be independent physician consultant Dr. Drew Updike.

More than four weeks since its last news broadcast, Monitor Mondays will return this coming Monday, Jan. 12, with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here the RACmonitor.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

The Whistleblower Update

Mon, 15 Dec 2025 13:00:00 -0500

Whistleblower attorney Max Volman will return to the next Monitor Monday broadcast to report the latest news about whistleblowers.

As we have learned, often “whistleblowers” are not insiders reporting wrongdoing; they tend to be outside the offending organization.

Broadcast segments will also include these instantly recognizable features:

● Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

● The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

● Legislative Update: Adam Brenman, legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

● Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Fatal Blow: “Statistically Valid Extrapolation”

Mon, 08 Dec 2025 13:00:00 -0500

For years, federal audit contractors have treated statistical extrapolation as the unassailable engine driving massive overpayment demands.

The premise sounds reasonable enough: review a small sample of claims, calculate an error rate, and multiply across the entire population to produce a "statistically valid" overpayment figure.

In a perfect world, this approach might hold up.

But healthcare isn't a perfect world.

It's a domain where coding is inherently subjective, documentation varies dramatically by provider, and even seasoned experts routinely disagree on the same chart. In this environment, extrapolation doesn't multiply truth—it amplifies uncertainty. Join us Monday during the long-running Monitor Monday when senior healthcare analyst Frank Cohen returns to the broadcast to debunk long-held beliefs regarding auditing, auditors and extrapolation.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Feds Blow the Whistle: A $45 Million Wound Care Settlement

Mon, 01 Dec 2025 15:00:00 -0500

The False Claims Act (FCA) suit was initiated by the U.S. government, not a traditional whistleblower. Nonetheless, the recent $45 million settlement with a Florida physician and his wound care group – Vohra Wound Physicians Management LLC – resolved allegations that group knowingly submitted claims to Medicare for medically unnecessary yet lucrative surgical procedures, when routine non-surgical wound management had actually been done.

During the next live edition of the long-running Monitor Monday Internet broadcast, famed whistleblower attorney Mary Inman will report the details of the amazing case, as a not-so-subtle reminder that crime doesn’t pay.

Broadcast segments will also include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Legislative Update: Matthew Albright, chief government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Providers Appear More Aggressive in Defending Revenue

Mon, 24 Nov 2025 14:00:00 -0500

It’s raining RACs. And many other third party auditors. It seems like every submission of medical records is being scrutinized for omission and commission. Then enter artificial intelligence (AI). The use of AI in auditing, although relatively new, is here to stay.

How is your facility faring compared to your peers? More audits? Less auditing? More denied claims? More money being recouped?

Now you can see for yourself how you’re doing comparing to others. Thanks to the annual benchmark study performed by MDaudit and shared here on Monitor Monday, you will be able to judge for yourself.

During the next live edition of the long-running Internet broadcast, Ritesh Ramesh, CEO for MDaudit, will share the findings of his company’s annual 2025 Benchmark study.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

New Audit Traps Revealed in the 2026 Medicare Physician Fee Schedule

Mon, 17 Nov 2025 12:00:00 -0500

The Centers for Medicare & Medicaid Services (CMS) recently released the 2026 Medicare Physician Fee Schedule. And while that’s not breaking news, the important news is that you and your team could benefit by understanding its hidden traps – so you can protect your revenue.

During the next live edition of Monitor Monday, senior healthcare analyst Frank Cohen will reveal the latest developments in Medicare audit reforms and statistical extrapolation, including the Medicare Program Integrity Manuel (MPIM) standards, plus how artificial intelligence (AI) is changing audit selection for 2025.

You and your team will receive expert analysis and practical guidance, as well as gain a better understanding of the true scope of improper payments.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

New Sepsis Definition Could Help You Achieve Denial Avoidance

Mon, 10 Nov 2025 14:00:00 -0500

Recently, a new version of the Sequential Organ Failure Assessment (SOFA) score was introduced.

Known as SOFA-2, this new definition aligns with organ dysfunction measurement in critically ill adults with current clinical practices, especially those diagnosed with sepsis.

Published in the Journal of the American Medical Association (JAMA) on Oct. 29 and available at https://jamanetwork.com/journals/jama/fullarticle/2840822, this revised tool updates the original 1996 SOFA score, which had remained unchanged despite evolving treatment modalities and technologies.

During the next live edition of Monitor Mondays, Dr. James S. Kennedy will discuss this SOFA-2 revision and its expected impact on clinical validation for sepsis – defined by Sepsis-3 as a life-threatening organ dysfunction caused by a dysregulated host response to infection – and how facility clinical workflows can negotiate denial avoidance with payers with this challenging diagnosis.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, senior healthcare legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

DME Supplier Pays $37 Million to Resolve FCA Allegations

Mon, 03 Nov 2025 12:00:00 -0500

Durable medical equipment (DME) supplier Semler Scientific Inc., along with a former distributor, Bard Peripheral Vascular Inc. and its related companies, have agreed to pay $37 million to resolve allegations that they violated the False Claims Act (FCA) by knowingly causing and conspiring to cause the submission of false claims to Medicare for photoplethysmography tests performed using the FloChec and QuantaFlo devices, in connection with the diagnosis of peripheral arterial disease (PAD), according to a report from the U.S. Department of Justice (DOJ).

For analysis and context, Mary Inman, partner in the law firm of Whistleblower Partners, will be the special guest during the next live edition of Monitor Mondays.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

A New Drug Crisis Soon Facing American Hospitals

Mon, 27 Oct 2025 15:00:00 -0400

America’s hospitals will soon face an unprecedented rebate-based prescription drug model, come Jan. 1 – that’s when there will be as many as 10 major drugs subject to Medicare price caps. This development is expected to create administrative and financial challenges for hospitals, which will have to pay the commercial price for such drugs while waiting for the rebates.

For analysis and context, Maureen Testoni, president and CEO for 340B, will be the special guest during the next live edition of Monitor Monday. She will also review a recent Congressional Budget Office (CBO) report, featured in a recent Senate committee hearing, that includes some misrepresentations about why the 340B program has grown in recent years.

As a special bonus, the longtime Internet broadcast produced by RACmonitor, will feature senior healthcare consultant Drew Updike, MD, who will recognize the tireless work being performed by the employees of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) who continue to work despite the federal shutdown, now in its fifth week.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The Lowdown on the Shutdown

Mon, 20 Oct 2025 12:00:00 -0400

This marks the third week of the federal government shutdown: an epic failure of congressional leaders from both political parties who couldn’t agree on how fund the government for the fiscal year that began Oct. 1.

And now many experts inside and outside of government believe this could be the longest shut down in history, surpassing the previous recordholder, which occurred, ironically, during the first term of President Donald Trump.

Reporting on the nuances of the federal government shutdown during the next edition of Monitor Mondays will be veteran ICD10monitor correspondent Timothy Powell. Powell is a regular panelist on the long-running Talk Ten Tuesdays Internet broadcast. In his day job, Powell, a certified public accountant (CPA), is a healthcare consultant.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

During Case Management Week: Unpacking Healthcare Cuts

Mon, 13 Oct 2025 14:00:00 -0400

You’re invited to go behind the scenes and listen as case managers tell their stories – of long hours, little sleep, and always being ambushed by a bell ringing for help.

These unsung heroes of healthcare are receiving their moment in the sun during the next live edition of Monitor Mondays, with a special 60-minute broadcast. The first half of the venerable weekly Internet broadcast will continue to bring you the news and information you’ve come to rely upon.

During the second segment, Patti Velky, American Case Management Association’s Board President, will report on the sweeping changes in the newly signed One Big Beautiful Bill Act (OBBBA). The law includes nearly $1 trillion in Medicaid cuts, potentially affecting 12 million people. Changes to state-directed payments and provider taxes could slash hospital funding by $340 billion. With key programs like Disproportionate Share Hospitals (DSHs), telehealth, and Hospital at Home still in limbo, the impact on hospitals, especially in Medicaid expansion and non-expansion states, will be profound. Case management teams will face mounting challenges in discharge planning, amid shrinking resources.

Also during the second half of the 60-minute broadcast, Mary Beth Pace, American Case Management Association’s Board President-Elect, will report on the one of case management’s toughest challenges: difficult discharges. With shrinking resources and limited post-acute options, getting “ready-to-go” patients safely discharged is harder than ever. Mary Beth will share new tactics and practical strategies to help case managers navigate these complex situations.

Finally, Adriana Peters, Board President for the Association of Physician Leaders in Care Management (APLCM), will report on how hospitals can turn data into action through the smarter use of metrics, KPIs, and analytics-driven storytelling.

The weekly broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Court Vacates RAVD 2023 Final Rule

Mon, 06 Oct 2025 12:00:00 -0400

Recently, a federal court vacated the Centers for Medicare & Medicaid Services 2023 Risk Adjustment Data Validation (RADV) Final Rule.

This action is reshaping the landscape for Medicare Advantage compliance. The rule had authorized contract-level extrapolation and eliminated the longstanding fee-for-service (FFS) adjuster — two changes that dramatically increased the potential scale of overpayment recoveries.

Reporting this developing story during the next live edition of Monitor Monday will be senior healthcare analyst Frank Cohen,

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Into a Rabbit Hole: Medical Loss Ratio Fraud Detected in Managed Care Program

Mon, 29 Sep 2025 12:00:00 -0400

A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO).
Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government’s fraud detection radar.
More on this topic will be reported during the next live edition of Monitor Mondays. That’s when whistleblower attorney Max Voldman returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.
The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Whistleblowers Bring Total Knee Replacement DME to its Knees

Mon, 22 Sep 2025 12:00:00 -0400

Three whistleblowers brought a durable medical equipment (DME) provider to its knees.

In two separate cases, the whistleblowers targeted Exactech, a manufacturer of total knee replacement (TKR) systems, resulting in a settlement of $8 million to resolve alleged violations of provisions of the False Claims Act (FCA).
Famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLP, will report the excoriating details of the settlement during the next live edition of Monitor Mondays.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley at Zelis, will report on the news happening at the intersection of healthcare and congressional action.

When Whistleblowers Can’t Whistle

Mon, 15 Sep 2025 12:00:00 -0400

Healthcare compliance just shifted fundamentally.
Traditional whistleblowers who needed inside access are being replaced by artificial intelligence (AI)-powered relators who mine public datasets and flag statistical anomalies that could signal fraud.
The U.S. Department of Justice (DOJ) logged 979 qui tam cases in 2024, many of which were reportedly triggered by mathematical outliers, rather than insider tips. Government agencies, such as the Centers for Medicare & Medicaid Services (CMS), have already recovered $820 million using algorithmic detection.
During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will reveal a possible solution for hospitals, health systems, and physician practices.
The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Audit Alert: Who’s Auditing AI?

Mon, 08 Sep 2025 12:00:00 -0400

Consider this a wake-up call.

As artificial intelligence (AI) quietly becomes part of the audit trail, healthcare leaders must ask a new question: who’s reviewing the reviewers?

During the next live edition of the venerable Monitor Mondays broadcast, contributing editor Sharon Easterling will break down why auditing AI tools are no longer a tech issue – they’re a documentation integrity and compliance priority.

Although this is an important topic for all healthcare professionals, register now to learn why it’s particularly relevant for those in compliance and revenue integrity.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Is the UPIC Fraud Prevention System Broken?

Mon, 25 Aug 2025 12:00:00 -0400

The Unified Program Integrity Contractors (UPICs) are household names in healthcare compliance.

But their track record tells a troubling story, according to senior healthcare analyst Frank Cohen. These Medicare fraud enforcement contractors are using controversial extrapolation techniques that providers successfully challenge over 60 percent of the time on appeal.

Cohen, who will be the special guest during the next live edition of Monitor Mondays, said he will examine how the 2016 consolidation created five regional enforcement powerhouses, along with why their statistical methodologies are devastating practices based on flawed assumptions. Cohen intends to show how misaligned incentives are creating systematic accuracy problems, while revealing why the current UPIC system might be fundamentally broken, despite everyone agreeing that fraud prevention matters.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

A Reign of Terror for Providers

Mon, 18 Aug 2025 11:00:00 -0400

There just might be a reign of terror being experienced at many of America’s hospitals and health systems. Professionally delivered patient care apparently seems to be getting hijacked by auditors compelled to deny claims of omission.

Aided by the Centers for Medicare & Medicaid Services (CMS) and abated by auditors private and public, the lingua franca appears be an entanglement of descriptors, namely “inpatient versus outpatient.”

During the next live edition of the venerated Monitor Monday broadcast, several of the most recognized names in healthcare will not add to the confusion, but offer advice for those on the front lines of battle.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Invalid Prescriptions Trigger CVS Omnicare Whistleblower Lawsuit

Mon, 11 Aug 2025 12:00:00 -0400

Although the lawsuit was filed by a pharmacist in New Mexico, a federal judge in New York has ordered CVS Omnicare to pay $949,000 to settle a False Claims Act (FCA) case.

According to news sources, the Pharmacy Benefits Manager (PBM) allegedly prescribed drugs to individuals in long-term residential facilities that were not supported by valid prescriptions and then submitted claims for reimbursement for those prescriptions to Medicare, Medicaid, and TRICARE. Although a jury trial was held last spring, with the judge rejecting post-trial arguments by Omnicare, it is understood that Omnicare plans to appeal.

Reporting details of this whistleblower lawsuit during the next edition of Monitor Mondays will be Max Voldman, a partner at Whistleblowers Law, LLP.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

340B: Fighting Back Against Big Pharma

Mon, 04 Aug 2025 13:00:00 -0400

Federal legislation has been introduced that is intended to help the beleaguered 340B Health organization via an effort to ban pharmaceutical companies from restricting access to the drug pricing discount program of the same name, through community and specialty contract pharmacies.

Reporting this lead story as well as other updates from Congress and the Trump Administration during the next live edition of Monitor Mondays will be Maureen Testoni, CEO for 340B Health and a frequent guest on the long-running broadcast. Testoni represents more than 1,600 hospitals and health systems participating in the 340B drug pricing program.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The Changing Audit Landscape

Mon, 28 Jul 2025 11:00:00 -0400

The rugged audit landscape has changed – and not for the better.

Today, there are more potential pitfalls and traps to capture the unprepared and impact them with huge fines and possible incarceration. In fact, the Centers for Medicare & Medicaid Services (CMS) has erected a legal fortress to protect their audit process. It’s not the same old ballgame – it’s a new one, with lots of new players.

It’s also why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to return to the broadcast to describe how you and your team can learn how to identify red flags in the process of fraud detection in order to avoid liability.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

An OPPS Oops?

Mon, 21 Jul 2025 12:00:00 -0400

The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for the 2026 fiscal year has been released.

Tucked inside the Proposed Rule from the Centers for Medicare & Medicaid Services (CMS) is the agency’s recommendation to phase out the Inpatient-Only List (IPO) over the course of the next three years.

Reporting the lead story on this development during the next edition of Monitor Mondays will be longtime panelist Ronald Hirsch, MD.

The weekly broadcast will also include these instantly recognizable features:

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Medicaid Madness

Mon, 14 Jul 2025 11:00:00 -0400

It’s a Medicaid Madness mess.

For many years, Medicaid has been providing support for America’s most vulnerable populations. But now, Medicaid finds itself as a pawn, being manipulated for political gain between two opposing forces: those who view the program as a means to an end to reduce government spending, and those who hold the opposite point of view.

Who will be the winners and losers? During the next live edition of the venerated Monitor Mondays, senior healthcare consultant Dennis Jones will report on how hospitals can save money in the face of the inevitable Medicaid cuts.

Jones, senior director of revenue cycle at Jefferson Health, was among the first of hand-picked subject-matter experts heard nearly 14 years ago on the weekly Internet broadcast produced by RACmonitor.

The Monday’s broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Sitting in for healthcare attorney David Glaser will be attorney Marguarite Ahman, a shareholder in the law offices of Fredrikson & Byron.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Chevron Deference: What Difference Has a Year Made?

Mon, 07 Jul 2025 13:00:00 -0400

Looking back and looking ahead, we must reckon with a major shift in America’s judicial landscape: the elimination of the so-called Chevron Deference. Last year, at about this same time, physician and attorney Dr. John K. Hall was the special guest here on Monitor Mondays, and he began his segment explaining the legal concept.

Now, more than a year after the U.S. Supreme Court’s landmark decision overturning 40 years of judicial precedent and upending statutory construction and enforcement, we must ask, has anything really changed?

Dr. Hall will return to examine the changes – or maybe lack of changes – and what we might still expect regarding legal challenges to executive actions.

The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior regulatory affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Breaking News: A Major Regulatory Shift

Mon, 07 Jul 2025 08:00:00 -0400

The Transparency in Coverage (TiC) Final Rule represents one of the most significant regulatory shifts in healthcare pricing since the implementation of the Patient Protection and Affordable Care Act.

During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will walk you and your team through the comprehensive labyrinth of changes.

Recent enforcement developments, including President Trump’s Executive Order 14221, directing actual hospital price disclosure within 90 days, also signal an intensified regulatory environment requiring proactive compliance strategies.

The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Moesha Baptiste, intern regulatory analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Fraud, Waste, and Abuse: The 2025 Triple Crown

Mon, 23 Jun 2025 14:00:00 -0400

Call it a trifecta, triumvirate, or the Triple Crown of 2025.

“Fraud, waste, and abuse” is the current triple-negative buzzword in America’s lexicon. And it’s being used to describe lots of things. But when that phrase is used by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), what does it actually mean?

You’ll learn during the next live edition of Monitor Mondays.

That’s when senior healthcare consultant Dr. Drew Updike – the broadcast’s special guest – will report on how the Acting HHS Inspector General (IG) Juliet Hodgkins used that phrase when she recently posted an online promotion in support of the OIG Spring Semiannual report to Congress.

The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Compliance Quicksand: Sepsis

Mon, 16 Jun 2025 13:00:00 -0400

Clinical denials by payers for sepsis continues. The problem: the definition of the enigmatic condition does not meet their propriety definitions.
Enter Dr. James Kennedy, who will be the special guest during the next live edition of the long-running Monitor Mondays broadcast. Dr. Kennedy will report on his recent conversations with the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, in which the agency described its protocols in amending the Index and Table to fit new diseases and terminology.
The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Medicaid Madness

Mon, 09 Jun 2025 12:00:00 -0400

The nation’s Medicaid program has seen better days. Recently, the federal government’s program to provide healthcare coverage to America’s low-income and vulnerable citizens was used as a bargaining chip as congressional Republicans were in the throes of budget negotiations, facing the daunting task to pass what President Trump calls his “big, beautiful bill:” a package of tax breaks disproportionately favoring the wealthy and spending cuts. The bill, which last week passed in the U.S. House of Representatives, is now making its way through the Senate.
Then there was the announcement this midweek that the Deputy Administrator and Director of the Center for Medicaid and Children’s Health Insurance Program (CHIP) Services, Drew Synder, was resigning from the federal agency.
Reporting on these developing stories during the next live edition of the long-running Internet broadcast Monitor Mondays will be Drew Updike, MD.
The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Whistleblower Update: Rheumatologist Sentenced to Jail, Must Forfeit Maserati and Other Possessions

Mon, 02 Jun 2025 13:00:00 -0400

During the next edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will provide an update on a whistleblower case that some consider “beyond bad.”

You’ll learn why a Texas rheumatologist who was sentenced to 10 years in prison and three years of supervised release was ordered to forfeit more than $28 million, plus 13 real-estate properties, a jet, and a Maserati GranTurismo sports car.

Inman, long considered one of the nation’s foremost whistleblower attorneys, will be the program’s special guest during the next live edition of the venerable Internet broadcast, coming up at 10 a.m. EST on Monday, June 2, 2025.

The long-running broadcast will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Field Report: Drew Updike will continue his reporting on efforts by the Trump Administration to intervene in healthcare issues – namely the Centers for Medicare & Medicaid Services (CMS) Form 64 related to migrants and Medicaid.

Tariffs: The Impact on Drugs

Mon, 19 May 2025 12:00:00 -0400

Welcome to a strange new world.

Recent tariffs announced by the Trump Administration are likely to impact drug manufacturing, since many drug components are produced outside the U.S., in nations such as in India, giving rise to state laws. Many states limit overseas involvement relative to the Health Insurance Portability and Accountability Act (HIPAA). Florida, for example, prohibits the offshoring of certain patient data, requiring such storage to be within the U.S.

Responding to this emerging crisis, the producers of RACmonitor and Monitor Mondays have invited Lexi Morrison, director of operations at MedPharma, to be the program’s special guest during the next live edition of the venerable Internet broadcast, coming up at 10 a.m. EST on Monday, May 19.

The long-running broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Speak No Evil: Asking Docs to Weigh In Became a $202 Million False Claims Act Settlement

Mon, 12 May 2025 12:00:00 -0400

On the surface, it was the perfect scam: kickbacks to docs in exchange for public speaking engagements, in order to induce them to prescribe drugs.

That’s apparently what Gilead Sciences thought.

But a whistleblower blew the whistle, and Gilead admitted to paying hundreds of thousands of dollars to high prescribers of their HIV drugs to serve as speakers at programs at luxury restaurants.

Famed whistleblower attorney Mary Inman, partner at Whistleblowers Partners, LLP, will report the savory details during the new live edition of Monitor Mondays, coming up at 10 a.m. EST on Monday, May 12.

The long-running broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Folan Houston, assistant general counsel for Zelis, will report on the news at the intersection of healthcare and congressional action.

• Field Report: Dr. Drew Updike continues his reporting on recent efforts by the Trump Administration to prevent providers from undertaking gender-affirming treatments for America’s LGBTQ+ population.

340B In the Crosshairs

Mon, 05 May 2025 11:00:00 -0400

Once again, the venerable 340B Drug Pricing Program finds itself in the crosshairs of critics – this time, from the U.S. Congress.

Recently, Sen. Bill Cassidy (R-La.), ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, released a report outlining his office’s investigation into the program.

During the next live edition of Monitor Mondays, 340B Health CEO Maureen Testoni will return to the broadcast to offer her response to the senator’s investigation.

The long-running broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior healthcare government affairs analyst for Zelis, will report on the news at the intersection of healthcare and congressional action.

Audit Alert: Immigration in Healthcare

Mon, 28 Apr 2025 12:00:00 -0400

Nearly every day, on any news service, images of people being quickly led away is chilling as the current Administration continues its sweep of rounding up and deporting suspected illegal immigrants.

Thus, in this current climate of increased audits, investigations and scrutiny on immigration, it is essential that healthcare organizations sponsoring foreign nationals for employment, ensure that documentation, policies, and practices are updated and fully compliant.

During the next live edition of the venerable Monitor Mondays live Internet radio broadcast, seasoned immigration attorney Matthew Webster will walk you through such essential issues as H-1B visas, L-1 visas and employment-based green cards. Webster is also expected to report on requirements from the Department of Labor (DOL) and the United States Citizenship and Immigration Services (USCIS).

Webster, senior immigration attorney at the law firm of Fredrikson & Byron, will discuss the impact of material changes when H-1B amendments are required.
The long-running broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on congressional action taking place in Washington, D.C.

FY 2026 IPPS: Hospital Strategy for Risk Adjustment, Equity, and Reimbursement

Mon, 21 Apr 2025 13:00:00 -0400

The fiscal year (FY) 2026 Inpatient Prospective Payment System (IPPS) proposed rule introduces significant reforms to hospital reimbursement, risk adjustment, and performance measurement.

Key changes include the Centers for Medicare & Medicaid Services (CMS) transition to HCC Version 28, the use of the Community Deprivation Index (CDI) for socioeconomic risk adjustment and expanded inclusion of Medicare Advantage data in quality metrics.

Launching in 2026, the proposed rule mandates episode-based payments with enhanced pricing accuracy. Hospitals must adapt by updating financial models, realigning quality strategies, and fostering cross-departmental collaboration. These changes emphasize equity, accountability, and transparency, all of which is designed to help in the positioning hospitals to lead in a value-driven healthcare environment.

Strategic readiness is critical to thrive under IPPS 2026. Reporting this story, during the next live edition of Monitor Mondays, will be the broadcast’s special guest Penny Jefferson.

The long-running broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Folana Houston, senior government affairs liaison for Zelis, will report on congressional action taking place in Washington, D.C.

• News Update: Dr. Drew Update will have an update to his recent reporting on transgender treatment practices.

HHS, CMS Latest Apparent Battlegrounds for Social Wars Being Waged by Trump Administration

Mon, 14 Apr 2025 14:00:00 -0400

A flurry of national news reports continues to document the large-scale restructuring taking place at the U.S. Department of Health and Human Services (HHS), where 10,000 jobs were reportedly slashed earlier this month, a move also impacting the workforce at the Centers for Medicare & Medicaid Services (CMS). An estimated 300 CMS workers are expected to be affected by this action, while NPR reported that the HHS teams focusing on sexual violence prevention were also eliminated – on the first day of April’s Sexual Assault Awareness Month.

Also recently, RACmonitor and Monitor Mondays have come into possession of a CMS memo, dated March 5, in which the agency warns that it may take action to prevent hospitals and other providers suspected of using “dangerous chemicals and surgical mutilation of children” relative to gender dysphoria, which the agency claims have “proliferated.” In fact, other executive actions taken by the Trump Administration also appear to have anticipated deleterious impacts on the health of America’s LGBTQ+ population.

It seems part of an overarching theme in which the Administration is waging social wars using gutted federal agencies more as a weaponized tactic than as a mechanism to serve the public.

Reporting this story during the next live edition of Monitor Mondays will be physician Drew Updike, a recognized leader in hospital utilization management, denials, clinical documentation integrity (CDI), coding, and hospital operations.

The long-running broadcast will also include these instantly recognizable features:

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, senior government affairs liaison for Zelis, will report on congressional action taking place in Washington, D.C.

• Monday Rounds: Dr. Shaemarke Magan, medical director for CaroMont Health in Gastonia, North Carolina, will make his Monday rounds, substituting for Dr. Ronald Hirsch.

Caught in the Crossfire: How to Avoid Pay-and-Chase Enforcement Tactics

Mon, 07 Apr 2025 14:00:00 -0400

A recent case, United States v. Junyi Liu, reveals how a $23 million fraud scheme exemplifies vulnerabilities in America’s healthcare system – as you’ll discover when senior healthcare analyst Frank Cohen joins the next Monitor Monday broadcast.

You’ll also learn about the challenges legitimate providers face when navigating complex regulations – and more about the government’s aggressive “pay-and-chase” enforcement tactics, plus why innocent practitioners often get caught in the crossfire.

During the next live edition of the venerable weekly Internet broadcast, Cohen will also report on potential policy reforms.

The long-running broadcast will also include these instantly recognizable features:

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, senior government affairs liaison for Zelis, will report on congressional action taking place in Washington, D.C.

• Monday Rounds: Dr. Bonney Olney, director of Level of Care Service for R1 RCM, will make her Monday rounds, substituting for Dr. Ronald Hirsch.

Wound Care: An Open Source for Audits

Mon, 31 Mar 2025 12:00:00 -0400

No matter the approach one might take for debridement, wound care continues to be an attractive source for audits – they inevitably arise and fester. Case in point: Wachler and Associates, a prestigious law firm in Michigan, currently is representing clients in some 18 wound care audit cases.

That is why RACmonitor, producers of Monitor Mondays, has invited Andrew “Drew” Wachler, founder of Wachler & Associates, to be the special guest during the next live edition of the venerable weekly Internet broadcast.

The long-running broadcast will also include these instantly recognizable features:

• Breaking News: Famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will report about a False Claims Act (FCA) settlement involving a Medicare Advantage provider.

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, senior government affairs liaison for Zelis, will report on congressional action taking place in Washington, D.C.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Advanced Beneficiary Notice: A Doctors’ Day Observance

Mon, 24 Mar 2025 13:00:00 -0400

National Doctors’ Day is actually Sunday, March 30, but the one-day nationwide observance is getting an early celebratory start during the next live edition of the venerable Monitor Mondays broadcast.

Joining our esteemed panelists will be three well-known physicians: Drs. Stephanie Van Zandt, Clarissa Barnes, and Juliet Ugarte Hopkins. And each doc will have an “open mic” during the 30-minute live Internet broadcast.

The long-running weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

At the Intersection of CDI and the False Claims Act

Mon, 17 Mar 2025 14:00:00 -0400

A clinical documentation integrity (CDI) professional who “knowingly … acts in reckless disregard of the truth or falsity of the information” may ultimately run into issues related to the federal False Claims Act (FCA).

The Medicare Fee-for-Service (FFS) Compliance Program on the Centers for Medicare & Medicaid Service (CMS).gov website lists several CMS compliance programs designed to educate and support Medicare providers in “understanding and applying” FFS policies. If the hospital compliance department is not monitoring these resources, it would be prudent for CDI leadership to do so, according to CDI expert Cheryl Ericson, who will be the special guest during the next live edition of the long-running Monitor Mondays Internet broadcast.

The venerable weekly Internet broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest news concerning healthcare legislation.

Why Complications are Complicated

Mon, 10 Mar 2025 13:00:00 -0400

Hospitals routinely measure, analyze, and track adverse patient harm events, collecting information about and reporting on certain types of such events in order to meet the Centers for Medicare & Medicaid Services (CMS) program and state legal requirements.

Prior work plans of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) revealed that hospitals reported few harm events to state reporting systems.

During the next live edition of Monitor Mondays, Dr. James Kennedy, president of CDIMD, will unwrap the January 2025 OIG proposal (OEI-06-18-00401) to evaluate hospital quality reporting, suggesting how hospitals’ clinical documentation integrity (CDI) and coding workflows can address errors of omission or commission.

Access the OIG’s announcement at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000907.asp.

The venerable weekly Internet broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs liaison for Zelis, will report on the latest news concerning healthcare legislation.

DEVELOPING STORY: No Public Comment Allowed for HHS Rulemaking

Mon, 03 Mar 2025 13:00:00 -0500

Across America, in sprawling university teaching facilities and in picturesque rural hospitals, administrators are dealing with a powerful tool called statistical extrapolation.

When auditors say that they’re using statistical “sampling” to review your Medicare claims, what they are often doing is using extrapolation – which could take what might appear to be minor discrepancies in your billing and turn them into major financial obligations.

To learn more about extrapolation and what it means for you and your team, the producers of RACmonitor have invited senior healthcare analyst Frank Cohen to be the special guest during the next live edition of Monitor Mondays.

The venerable weekly Internet broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior government affairs liaison for Zelis, will report on the latest news concerning healthcare legislation.

Hot Off the Presses: Latest Issues Impacting Medicare Home Health Care, Hospice, and Medicaid Services

Mon, 24 Feb 2025 12:00:00 -0500

During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medicare home health payment model, Medicare Advantage (MA) claim denials in post-acute care, and increasing threats to Medicaid support.

The venerable weekly Internet broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest news concerning healthcare legislation.

1.2 Billion in Fraudulent Claims for Wound Care Procedures

Mon, 17 Feb 2025 12:00:00 -0500

Evoking the age-old adage of having “skin in the game,” a Phoenix, Arizona couple last month entered a plea of guilty to one of the largest healthcare frauds in U.S. history.

The couple pleaded guilty to criminal charges involving the submission of $1.2 billion in fraudulent claims to Medicare, Medicaid, and other insurers for wound care procedures. The husband-and-wife team have agreed to pay more than $600 million in restitution and face over 20 years in prison, according to famed whistleblower attorney Mary Inman, who will return to Monitor Mondays for its next edition.

The venerable broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs liaison for Zelis, will report on the latest news concerning healthcare legislation.

Major Challenges Facing American Hospitals Explained

Mon, 10 Feb 2025 12:00:00 -0500

Challenges in reimbursement, benchmarking, and quality reporting are being experienced in many American hospitals. Why is this problem arising?

Our special guest during the next live edition of Monitor Mondays will have answers. Penny Jefferson, a seasoned healthcare professional who serves as the Director of Clinical Documentation Integrity (CDI) Services at the University of California at Davis Medical Center, will report on why misinterpretation of the admission types appears to be the culprit, impacting compliance, payment, and patient safety indicators (PSIs).
The broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior government affairs liaison for Zelis, will report on the latest news concerning healthcare legislation.

Artificial Intelligence and Healthcare: Three Critical Areas You Need to Know About

Mon, 03 Feb 2025 13:00:00 -0500

Artificial intelligence (AI) is becoming as commonplace in healthcare as billing audits.
It’s ubiquitous.
And that is why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to explore the intersection of AI and healthcare. So, during the next live edition of the venerable live weekly Internet broadcast, Cohen will address key concerns for compliance professionals, including Health Insurance Portability and Accountability (HIPAA) requirements, data governance, and responsibility in AI-driven decision-making.
The broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest news concerning healthcare legislation.

Stargate Promises New Advancements in Medicine. Compliance Unclear

Mon, 27 Jan 2025 13:00:00 -0500

Earlier this week, in the wake of the inauguration of President Donald Trump, a major announcement was made that some hope will lead to new advances in healthcare: “Stargate,” a private venture to build in the U.S. hyperscale data centers for artificial intelligence (AI). The strategic goal is to make the United States the world’s leader in AI.

Larry Ellison, founder of the relational database company Oracle, indicated that much work in this project will be focused on healthcare, including the promise of better medical diagnostics and imaging, personalized medicine, remote monitoring, and telehealth for patients, according to Edward M. Roche, RACmonitor investigative reporter, whose day job is director of scientific intelligence for Barraclough New York LLC.

Roche will be reporting this lead story for the next edition of the long-running Monitor Mondays weekly broadcast.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs liaison for Zelis, will report on current healthcare legislation.

Major False Claims Act Settlement Snags New York’s Independent Health

Mon, 13 Jan 2025 12:00:00 -0500

New York health insurer Independent Health and its former executive reached a settlement that will amount to up to $100 million with the U.S. Department of Justice (DOJ) and a whistleblower over False Claims Act allegations that they made Medicare members appear sicker than they really were to get more money from the government, a practice known as risk adjustment fraud.

Betsy Gaffney, former CEO of now-defunct vendor DxID, agreed to pay $2 million to resolve allegations she helped DxID mine patients’ medical records for diagnoses that risk-adjust, nudging doctors to approve them up to a year after the patient visits, all while pocketing up to 20 percent of the additional revenue generated for Independent Health by these unsupported diagnoses.

Reporting the lead story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm Whistleblower Partners.

More than four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here and in RACmonitor.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior government affairs liaison for Zelis, will report on current healthcare legislation.

Register now to listen to this exclusive news edition of Monitor Mondays; all this and more will be coming up at 10 a.m. EST on Jan. 13, 2024.

May I have the Envelope: 2024 Healthcare Heroes to be Revealed

Mon, 16 Dec 2024 12:00:00 -0500

“He’s making a list, checking it twice…”

With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare.

Calling them “Hirsch’s Heroes,” an annual tradition that began in 2015, Hirsch will reveal those to whom he has bestowed the esteemed honor during the next live edition of Monitor Mondays.

Other broadcast segments will include these instantly recognizable features:

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Field Report: Phyisican and attorney Dr. John K. Hall is expected to file a field report on the recent Anthem Blue Cross Blue Shield proposal relative to its anethesia policy which the giant payer has since abandoned.

• Legislative Update: Matthew Albright, chief leglistative affairs analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Health Insurers in the Spotlight in the Wake of CEO Slaying

Mon, 09 Dec 2024 12:00:00 -0500

Have you ever had your insurance company deny payment for your claim?

Have you ever had your insurance company stall or deny a pre-authorization?

How long did it take to get the authorization for the medication you’ve been using to keep yourself alive for the past few years? Was it maddening?

During the next edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine the frustration that modern health insurance has become – especially in the context of the recent fatal shooting of a prominent health insurance chief executive officer (CEO).

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

National Audit News Roundup

Mon, 02 Dec 2024 14:00:00 -0500

It’s raining recovery auditors.

More denials. More grief. More lost revenue and more palpable anxiety.

The seemingly unending war between payers – private and public – and providers continues unabated. The ubiquitous Two-Midnight Rule and the contentious subject of observation versus inpatient status have become an indelible part of America’s healthcare system.

And that is why the producers of RACmonitor have dedicated the next live edition of the venerable Monitor Mondays Internet broadcast to be the go-to source for the latest audit and regulatory news: a veritable feast of valuable information for you and your team to use.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Substituting for Dr. Ronald Hirsch will be Dr. Tripti Katari, who will be making her Monday Rounds. Dr. Katari is expected to report on updates on the American Medical Association (AMA), which she serves as Legislative Counsel.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

How E&M Code Misuse Triggered an FCA Settlement

Mon, 25 Nov 2024 13:00:00 -0500

$23 million: that’s the amount that the University of Colorado Health, also known as UCHealth, has agreed to pay to resolve False Claims Act allegations related to its seeking and receiving payment from federal healthcare programs for visits to its emergency departments.

The university, headquartered in Aurora, was accused of falsely coding certain Evaluation & Management (E&M) claims submitted to the Medicare and TRICARE programs.

Reporting the lede story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1-RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

New Healthcare Survey Reveals Need for Continuous Financial Risk Monitoring

Mon, 18 Nov 2024 13:00:00 -0500

As we continue to monitor and review the latest healthcare news, we are always pleased when word of a new study comes to our attention – especially when the study is within the purview of MDaudit.

During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report the latest results of a new national study – and how the salient takeaway points could help you and your team as you grapple with the dynamic environment of America’s healthcare system.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1-RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Simplifying the Two-Midnight Rule: Simple as 1, 2, 3

Mon, 11 Nov 2024 11:00:00 -0500

Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements.

For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials.

During the next live edition of the venerable Internet radio broadcast, Dr. Kartchner will complete his discussion as to how detailed clinical updates, assessments, and rationale for continued hospitalization can preemptively address payer scrutiny and reduce denials while optimizing reimbursement for patient care.

Other segments during the weekly broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Denials Going from Bad to Worse

Mon, 04 Nov 2024 12:00:00 -0500

Denials in healthcare are a problem.

Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA).

Hut reports that MA plans are classifying hospital stays as outpatient observation visits at a significantly higher rate than traditional Medicare even though the rule is supposed to be applied the same way in both programs.

And Hut believes the situation is likely to be getting worse because UnitedHealthcare is targeting provider coding while it seeks to bring down medical spending that has been higher than anticipated in recent fiscal quarters.

Hut will be reporting this story during the next live edition of Monitor Mondays. He has more than 12 years reporting healthcare policy news and trends.

Other segments during the weekly broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Sex, Lies and Turmoil

Mon, 28 Oct 2024 13:00:00 -0400

A pediatrician under investigation related to accusations that she had engaged in sexual relations with a male patient, having lied about it when applying for another healthcare position, was recently sentenced for making false statements.

In another case, a federal contractor agreed to resolve False Claims Act allegations in connection with a government contract related to its storage of unsecured personally identifiable information of Medicare beneficiaries.

Recognizing that it’s not only a bad idea, but also a crime to lie to a government agency, Monitor Monday’s own attorney and physician Dr. John K. Hall will report on how your organization’s cybersecurity could put you at risk of false claims liability during the next live edition of the long-running Internet radio broadcast. Specifically, Dr. Hall will review these two recently resolved cases and offer tips to avoid liability.

Other segments during the weekly broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Two-Midnight Rule: Presumption of Risk

Mon, 21 Oct 2024 15:00:00 -0400

Could you and your care team be at risk when you upgrade a patient from observation to inpatient simply because the patient passed a second midnight in the hospital, based on the Centers for Medicare & Medicaid Services (CMS) contentious Two-Midnight Rule?

And what about the expectation? How does expectation enter this equation? And finally, what should be present to change that expectation?

During the next live edition of Monitor Mondays, Ben Kartchner, MD, a prominent physician advisor, will thread the needle of this controversial regulation to give his perspective on how the two-midnight expectation can serve as your compass, helping you steer through regulatory challenges, ensure compliance, and prevent unnecessary denials.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

False Claims Act Violation: Unnecessary Drug Testing Flags Feds

Mon, 14 Oct 2024 12:00:00 -0400

The U.S. Department of Justice (DOJ) has reported that one of America’s largest urine drug-testing companies has agreed to pay $27 million to resolve allegations of unnecessary drug testing and illegal remuneration to physicians.

The False Claims Act allegations resolved by this settlement were originally brought in three lawsuits filed by whistleblowers under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government – and to share in any recovery.

Reporting on this major story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLC. Other segments during the weekly Internet broadcast will include these instantly recognizable features:

•Monday Rounds: Juliet Ugarte Hopkins, MD, will be making her Monday Rounds.

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

•Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

340B Drug Rebates: Old Debate Revived, But Shot Down

Mon, 07 Oct 2024 13:00:00 -0400

A major drug company’s attempt to turn 340B drug pricing program discounts into rebates made big headlines in recent weeks. Maureen Testoni, president and CEO of 340B Health, will review how this potentially major upheaval came about, how 340B stakeholders responded, and how the drugmaker backed off after the federal government threatened it with massive penalties.

This debate is by no means over.

The idea of imposing rebates in 340B is not a new one, and the concept has come back into prominence recently amid the ongoing implementation of the Inflation Reduction Act, which will have important effects on 340B.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Violence in America’s Hospitals

Mon, 30 Sep 2024 12:00:00 -0400

As violent crime has trended slightly downward throughout the United States over the last year, a wound to this country’s collective psyche that appears reluctant to close is workplace violence in America’s hospitals.

Reporting the lead story during the next live edition of Monitor Mondays will be special assignment contributor Dennis Jones, senior director of revenue cycle at Jefferson Health.

Jones returns to his beat to continue his reporting of this issue. Among those healthcare professionals most at risk for workplace violence are nurses and those who work in emergency rooms. In fact, a 2021 study conducted by the Cleveland Clinic revealed that workplace violence tends to be four times more prevalent in healthcare than in other industries. Jones is expected to have more details on “Violence in America’s Hospitals.”

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, senior government analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Whistleblower Report: Oak Street Health Agrees to Pay $60M to Resolve Alleged False Claims Act Liability in Medicare Advantage Patient Recruitment Scheme

Thu, 26 Sep 2024 12:00:00 -0400

Oak Street Health, headquartered in Chicago and a wholly-owned subsidiary of CVS Health since 2023, has agreed to pay $60 million to resolve allegations that it violated the False Claims Act by paying kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street Health’s primary care clinics, according to a news release issued by the U.S. Department of Justice (DOJ). Reporting the lead story during the next live edition of Monitor Mondays will be Max Wollman, a partner in the Washington office of Whistleblower Partners, LLP.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Joseph Stinson. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Mr. Stinson is expected to receive $9.9 million, according to the DOJ.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

•Legislative Update: Adam Brenman, senior government analyst for Zelis, will report on current healthcare legislation.

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Exposing Challenges to Getting Paid by Medicare Advantage

Mon, 16 Sep 2024 12:00:00 -0400

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays.

Pace, in making the statement, was referring to rules and regulations set forth in the Federal Register for Medicare in 2024. She also alleges that some Medicare Advantage (MA) plans are not abiding by some of those rules and regulations. Pace says all MA plans need to abide by the IPO and reimburse correctly.

But does your facility have the processes in place to ensure that you are being paid correctly for surgical procedures on the IPO? Be sure to listen in order to find out.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

How to Ensure Correct Inpatient Status

Mon, 09 Sep 2024 14:00:00 -0400

What’s wrong with this picture?

With more than 10 years of the Centers for Medicare & Medicaid Services (CMS) Two-midnight Rule now behind us, one would presume that most healthcare professionals should know what determines an inpatient status. But some don’t.

That is why RACmonitor has invited renowned physician and attorney Dr. John K. Hall to report on the requirements and risks associated with inpatient order documentation during the next edition of Monitor Mondays.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

New Study Reveals America’s Big Hang-up with Healthcare

Mon, 26 Aug 2024 12:00:00 -0400

A comprehensive new survey featuring responses from more than 1,500 U.S. patients reveals that they are not only frustrated by poor provider support, but also are experiencing tangible health setbacks – especially when waiting to refill prescriptions and being placed on hold while waiting to speak to a caregiver.

Israel Krush, CEO and Co-Founder of Hyro, the healthcare vendor whose company sponsored the survey, is scheduled to be the special guest during the next live edition of the long-running Internet broadcast Monitor Mondays, produced by RACmonitor.

Hyro’s “Voice of the Patient” survey and accompanying report highlight significant gaps between patient needs and the current support available through healthcare delivery channels.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Federal Officials Announce Medical Relief in Wake of Hurricane

Mon, 19 Aug 2024 14:00:00 -0400

In response to the devastation caused by Hurricane Debby, now Tropical Storm Debby, the Centers for Medicare & Medicaid Services (CMS) has announced additional resources and flexibilities to support the affected states of Florida, Georgia, and South Carolina.

Following President Biden’s emergency declarations and U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra’s Public Health Emergency determination, CMS is working closely with these states to ensure continued access to critical healthcare services.

Importantly, CMS is offering state waivers and other support to help healthcare providers in the impacted regions maintain operations and deliver essential care during this challenging time, according to Timothy Powell, an independent senior healthcare consultant, who also serves as the national correspondent for ICD10monitor and will be the special guest for the next edition of Monitor Mondays.

Other segments during the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

There’s a New Sheriff in Town: New DOJ Program Intends to Snare Even More FCA Fraudsters

Mon, 12 Aug 2024 15:00:00 -0400

The U.S. Department of Justice (DOJ) has a new whistleblower reward initiative called the DOJ Corporate Whistleblower Awards Pilot Program.

The Program, which seeks to fill gaps left by existing whistleblower reward programs, incentivizes whistleblowers to bring tips to the DOJ about types of healthcare fraud not already covered by the False Claims Act (FCA). According to Monitor Mondays special guest Mary Inman, the new Program raises the stakes for the entire healthcare industry, especially among those who typically ignore or disregard internal reports concerning whistleblowers.

Other segments during the next edition of the weekly Internet broadcast will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

FY 2025 IPPS: The Clinical Report

Mon, 05 Aug 2024 16:00:00 -0400

The Inpatient Prospective Payment System Final Rule for Acute Care and Long-Term Care hospitals in the 2025 fiscal year (FY) continues to generate interest from providers, payers, hospital administrators, vendors, and consultants. But what are the significant takeaways for stakeholders as they prepare for the government’s fiscal year, which begins Tuesday, Oct. 1, 2024?
Standing by to report the lead story during the next live edition of the long-running Monitor Mondays broadcast will be subject-matter expert Dr. James Kennedy.
Other broadcast segments will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

“Do the Crime, Pay the Fine:” DaVita to Pay$34 million to Resolve Allegations of Illegal Kickbacks

Mon, 29 Jul 2024 12:00:00 -0400

Denver-based DaVita Inc. has agreed to pay slightly more than $34 million to resolve allegations that it violated the False Claims Act (FCA).
The U.S. Department of Justice (DOJ) reported in a news release that DaVita paid kickbacks to induce referrals to DaVita Rx, a former subsidiary that provided pharmacy services for dialysis patients, directing the payments to nephrologists and vascular access physicians.
During the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman will report the details on this amazing story, focusing on the provisions of the Anti-Kickback Statute that prohibit anyone to induce referrals of patients or items for services covered by Medicare, Medicaid, and other federally funded programs.
Other broadcast segments will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Kate Choe, an undergraduate student at Brown University who is also interning at Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

End of the Road for the ALJs?

Mon, 22 Jul 2024 11:00:00 -0400

Could the end be near for the administrative law judges of the Centers for Medicare & Medicaid Service (CMS). What about the Office of Medicare Hearings and Appeals (OMHA)? Could these entities be gone from the audit landscape?

Case in point: the Supreme Court (SCOTUS) continues eviscerating executive powers. This time SCOTUS has limited the authority of administrative tribunals and the administrative law judges to adjudicate some cases—this according to a recent SCOTUS decision.

While the actual case relates to administrative hearings at the Securities and Exchange Commission (SEC), the limitations likely transcend that agency.

During the next live edition of Monitor Monday, physician and attorney, Dr John K Hall, will discuss the potential impacts of the decision and what impact it might have on Office of Medicare Hearings and Appeals (OMHA) and the Centers for Medicare & Medicaid Services (CMS) administrative law judges.

Other broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Handle with Care: Taking Steps for Safe Transitions

Mon, 15 Jul 2024 14:00:00 -0400

Have you ever wondered how professional movers carefully pack everything? From expensive china to precious crystal stemware, they seem to have a knack and knowledge for how to prepare.

When it comes to healthcare, how safe is the transition from hospital to home if a patient cannot get the services they need at home when they are ready to transition?

More and more, we are seeing challenges with home health care agencies not being available for our patients who need home care at discharge, according to Mary Beth Pace, vice president of care management at Trinity Health. During the next live edition of the long-running Monitor Mondays live broadcast, acting as special guest, she will unpack all the important steps for ensuring safe transitions.

Other broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

No More Chevron? What Happens Next?

Mon, 08 Jul 2024 12:00:00 -0400

For nearly four decades, a judicial principle known as “Chevron deference” has guided the federal courts as they reviewed litigation associated with federal agencies. Chevron deference allowed legislators to leave statutes somewhat vague, assuming that an agency full of government experts would sort out the details and promulgate effective regulation.

But, according to a recent U.S. Supreme Court (SCOTUS) decision, the principle is fundamentally flawed – in fact, fatally flawed. The decision throws it out in its entirety. This has the potential to upend years of U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) regulation.

Distinguished physician and attorney Dr. John K. Hall will report on the resultant doom and gloom of potential outcomes, and how it may affect providers and payers, during the next live edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Special Alert: DOJ Cracks Down on Nearly 200 Involved in Major Healthcare Fraud Schemes

Mon, 01 Jul 2024 12:00:00 -0400

In a late-breaking press release, the U.S. Department of Justice (DOJ) announced late Thursday that the agency had charged nearly 200 individuals accused with involvement in various healthcare fraud schemes estimated at $2.7 billion. Charges were brought against nurses, physicians, and others in a national sweep, and it was estimated that more than $900 million in false claims were submitted to Medicare for wound care grafts.

Reporting on this major developing story during the next edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLC.

Broadcast segments will also include these instantly recognizable features:

• Perspective: RACmonitor investigative reporter Edward M. Roche, founder of Barraclough New York, LLC, where he serves as the director of business intelligence, will go behind the proverbial curtain to ascertain if artificial intelligence (AI) is the latest marketing fad or a promising solution to advance healthcare delivery in the U.S.

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

How a Different Type of Whistleblower Created a Lesson Worth Learning

Mon, 24 Jun 2024 13:00:00 -0400

A recent federal court decision in New Jersey demonstrates the viability of a different kind of whistleblower – in this case, a privately defrauded party.

The most common type of a whistleblower under the False Claims Act (FCA) tends to be a corporate insider who sees fraud committed against the government by their employer or a company they work with, and generally after many, many attempts at internal reporting, sues the company under the law and is eligible to share in the recovery.

During the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner of Whistleblower Partners, LLC, will report on how this uncommon type of whistleblower has created a lesson worth learning for healthcare leaders.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Human Touch at the Intersection of Artificial Intelligence and Denied Claims

Mon, 17 Jun 2024 13:00:00 -0400

Artificial intelligence (AI) is fast becoming a fixture in healthcare revenue cycle management (RCM), where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision.

During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report on why keeping humans in the loop is the best strategy for preventing negative outcomes.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Juliet Ugarte Hopkins, MD, substituting for Dr. Ronald Hirsch, will be making her Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

OIG On the Prowl: Semi-Annual Report to Congress

Mon, 10 Jun 2024 11:00:00 -0400

They’re looking for fraudsters, going on the prowl for bad actors, as revealed in the latest semi-annual report to Congress compiled by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In this latest report, the government watchdog identified more than $2.76 billion in expected recoveries and receivables.

Providing analysis and context for the OIG report released June 3 during the next edition of Monitor Mondays will be James S. Kennedy, MD, a subject matter expert who will review highlights and offer suggestions for remaining compliant.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Jail Time, or Hefty Fine?

Mon, 03 Jun 2024 12:00:00 -0400

Most healthcare investigations by the U.S. Department of Justice (DOJ) result in settlements. Many times, the complete details of the settlements in underlying government cases are not fully disclosed. But sometimes, a provider ends up at trial. And when that happens, it often offers insights into what it takes to get hit with hefty fines – and possible prison time, if you lose the case.

During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will review two recent convictions against individual physicians, and offer suggestion for avoiding big payouts and incarceration.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

New Medical Technologies: Are They Audit-Proof?

Mon, 20 May 2024 16:00:00 -0400

A deep dive into microbiology can reveal an up-close look at the cells that make up organs of the human body – and corresponding cancer treatments that leave no trace of damage.

The science of medicine appears to be moving at the speed of light lately. But will new healthcare technologies be audit-proof? Monitoring these escalating changes and their impact on America’s delivery of healthcare services during the next live edition of Monitor Mondays will be RACmonitor investigative reporter Edward M. Roche.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Clarrisa Barnes, MD, President and CEO for the American College of Physician Advisors, is substituting for Ronald Hirsch to report on her Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Healthcare Whistleblower Roundup: Recent Settlements Reach Nearly $10 Million

Mon, 13 May 2024 13:00:00 -0400

Two recent settlements to resolve allegations of violating the False Claims Act – both involving the virulent COVID-19 – are the latest in a series of actions that will be reported on during the next edition of Monitor Mondays by famed whistleblower Mary Inman, who also notes that her company, Whistleblower Partners, LLP, is poised to announce another major case pending the unsealing of court documents expected this week.

Among the two cases, one involves the U.S. and California versus ReNew Health Group, LLC and two of the firm’s executives. The settlement alleges that the company knowingly submitted false Medicare Part A claims for nursing home residents. The other settlement involves Atlanta-based Insight Global LLC, which allegedly failed to implement adequate cybersecurity measures to protect personal health information of individuals involved in contact tracing efforts.
Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The AI Arms Race in Healthcare Auditing: Handicapping Winners and Losers

Mon, 06 May 2024 12:00:00 -0400

The arms race is heating up.

On one side there are healthcare providers, and on the opposing side, an army operated by the auditors. Who will be the winners and losers?

Are you safe? And how do you protect your facility from claim denials and takebacks, especially when auditors are using artificial intelligence (AI)?

RACmonitor investigative reporter Edward M. Roche will return to Monitor Mondays this coming Monday to report on the escalating AI arms race. Roche, who just completed an exclusive three-part series for RACmonitor on AI auditing, will also report on essential steps you and your colleagues can deploy in defense of such audits.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Value of Peer-to-Peer Discussion

Mon, 29 Apr 2024 12:00:00 -0400

Do you have peer-to-peer (P2P) discussions?
Are they useful? Are they valuable? And how do you know?
Our own physician and attorney, Dr. John K. Hall, will offer his unique take on the value of P2P interactions and how you should measure it during his appearance as Guest Panelist on the next upcoming edition of Monitor Mondays.
Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Matthew Albright, a senior government affairs liaisons for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Two-Midnight Rule: Navigating Treacherous Medicare Currents

Mon, 22 Apr 2024 13:00:00 -0400

Like seasoned harbor pilots navigating tugboats through natural and manmade hazards, physician advisors each day face the daunting task of guiding their hospitals through a labyrinth of Medicare rules and regulations.

Reporting on those conditions during the next edition of Monitor Mondays will be the vice chair of the recently concluded national conference of the American College of Physician Advisors, Stephanie Van Zandt. In that role, Dr. Van Zandt had a front-row seat to the history-making conference that concluded Thursday in Coronado, Calif. Dr. Van Zandt is expected to report on the key Medicare policy issues that continue to define the role of physician advisors.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Defense Strategies Against AI Audits

Mon, 15 Apr 2024 12:00:00 -0400

Artificial Intelligence (AI) software is now in the “hype phase” of adoption.

It promises to increase the efficiency of medical audits. But also, AI is being touted as being able to handle much more data, examine many more cases, and instantly make decisions regarding medical necessity or inadequate documentation.

The number of audits can be doubled, tripled, quadrupled. Why take samples for review when AI can audit every single claim submitted? Providers can expect a deluge of demands for recoupment, all delivered with exquisite and compelling prose.

But is AI as accurate or as thorough or efficient as promised? During the next live edition of Monitor Mondays, RACmonitor investigative reporter Edward M. Roche will review basic defense strategies that providers can deploy against such audits, and look into the future to uncover some of the problems on the horizon.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Bart Daniels, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Legislative Update: Cate Brantley, senior government affairs liaisons for Zelis, will report on current healthcare legislation.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Medicare Advantage “Schemes” in the DOJ Crosshairs

Mon, 08 Apr 2024 11:00:00 -0400

The recent $37 million settlement against Cigna regarding enhancing risk adjustment factor (RAF) scores —along with related litigation by the U.S. Department of Justice (DOJ)— highlight the aggressiveness of the federal government to crack down on entities for non-compliant billing practices.

During the next live edition of Monitor Mondays, Dr. James Kennedy will unpack the challenges entities have with this hot billing compliance issue. Dr. Kennedy will also recommend an approach that attempts to clarify what facilities and physicians can do to mitigate their risks.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Whistleblower Update: $300 Million in Alleged Fraud

Mon, 01 Apr 2024 12:00:00 -0400

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit that accuses Martin’s Point Health Care, along with five other providers in other states, of defrauding the government of more than $300 million, pertaining to allegations that the providers inflated patients’ risk scores to obtain higher payments to which they were not entitled from the government’s military health plan.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Whistleblower Report: Famed whistleblower attorney Mary Inman, founder of Whistleblowers Partners, returns to Monitor Mondays with recent news of healthcare whistleblowers.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

How to Achieve a Clear Vision for Hospital Price Transparency

Mon, 25 Mar 2024 12:00:00 -0400

Since its launch in January 2021, the Hospital Price Transparency Rule from the Centers for Medicare & Medicaid Services (CMS) has been a vexing issue for many of America’s hospitals. Despite enforcement efforts from CMS, implementation for many providers has been onerous – so much so that when the latest requirements were issued by CMS, one could imagine provider executives simply giving up, rationalizing that non-compliance was the cost of doing business.

But now there’s a chance for your team to achieve a clear vision for implementing the arduous tasks of compliance. During the next live edition of Monitor Mondays, Jory Hatton, CEO for ClaraPrice, will outline a list of actionable items that need to be executed in order to be compliant, as he concludes this essential three-part series.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, state analyst for Zelis, will report on current healthcare legislation.

The Fix is in: Hospital Price Transparency Rule

Mon, 18 Mar 2024 15:00:00 -0400

Many of America’s hospitals continue to be challenged as it pertains to complying with the requirements from the Centers for Medicare & Medicaid Services (CMS) for implementing the agency’s rule on hospital price transparency. And that is why RACmonitor and Monitor Mondays are producing a three-part series, in collaboration with ClaraPrice, to help providers fix this vexing problem, including addressing the onerous requirement for hospitals to produce their own machine-readable files (MRFs).

Specifically, CMS is requiring hospitals to display their standard charge information in a CMS template layout, following data specifications and a data dictionary.
But there’s even more stringent requirements from CMS that providers also must address.

During the next live edition of Monitor Mondays, Jory Hatton, ClaraPrice CEO, will continue with the second part of this essential series to help ease the pressure to comply.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

Empowering the Bedside Physician to Lower Observation Rates

Mon, 11 Mar 2024 14:00:00 -0400

America’s hospitals are currently facing a critical challenge: a flood of patients placed under observation, leading to lost revenue and operational disarray. Amid the confusion, questions arise. Even seasoned bedside physicians struggle with uncertainty in determining patient status upon admission.

But fear not! There is hope in this chaotic landscape, unlocked by empowering the bedside physician to invoke the full potential of the Centers for Medicare & Medicaid Services (CMS) Two-Midnight Rule.

During the next live edition of Monitor Mondays, Dr. Stephanie Van Zandt from BayCare Health System in Florida will report on an innovative four-part process meticulously crafted by her team. She will explain strategies aimed at empowering emergency department (ED) providers and admitting hospitalists through comprehensive education on patient status determination.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.

Hospital Price Transparency Rule: An Important Update

Mon, 04 Mar 2024 12:00:00 -0500

There was a time when everyone in healthcare compliance and revenue cycle management was scrambling to implement the Hospital Price Transparency Rule.

Now, nearly four years later, it’s back.

The Centers for Medicare & Medicaid Services (CMS) 2024 Final Rule for Price Transparency marks the biggest change to the rule requirements since it initially took effect in January of 2021.

The new mandate introduces a three-phase approach that began in January and will continue with new requirements effective in July, with additional requirements starting in January 2025. New technical mandates will introduce new challenges for hospitals, potentially forcing facilities out of compliance and creating a need for outside expertise to dig up pricing information and generate new data formats.

With the new mandates will also come increased numbers of CMS audits, warning letters, and non-compliance notices, as the federal government begins to automate the auditing process.

During the next live edition of Monitor Mondays, Jory Hatten, CEO for ClaraPrice, will report on this topic of vital importance.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, state legislative analyst for Zelis, will report on current healthcare legislation.

Updated Episode | Chevron Deference: What Happens if There’s No Deference?

Mon, 04 Mar 2024 10:00:00 -0500

What happens if the Supreme Court of the United States (SCOTUS) dismantles decades of government agency discretion? Recent cases at SCOTUS indicate that this could happen. But what would be the consequences?

During the next live edition of the long-running Internet radio broadcast Monitor Mondays, RACmonitor’s own physician and attorney Dr. John K Hall will consider the ramifications of the demise of the so-called “Chevron Deference” currently enjoyed by federal agencies.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.

Artificial Intelligence: Examining Promises, Skepticism, and Ethical Implications

Mon, 19 Feb 2024 11:00:00 -0500

The implementation of generative artificial intelligence (AI) in the Electronic Health Record (EHR) is one of several hot-button issues to be explored during the next live edition of the Monitor Mondays, the long-running Internet broadcast produced by RACmonitor.

Other high-level considerations to be reported include leveraging AI in regulatory compliance, creating physician notes from doctor-patient conversations, and how AI could bridge knowledge gaps.

Reporting on these latest developments in healthcare technology will be senior healthcare consultant Sharon Easterling. Since 2012, Easterling has played a pivotal role in supporting companies as they integrate natural language processing (NLP) and machine learning into their coding and clinical documentation integrity (CDI) technology, utilizing algorithms. During the broadcast, her focus will be more sharply focused on advancing initiatives within healthcare AI and leveraging AI technology.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, federal legislative analyst for Zelis, will report on current healthcare legislation.

What’s the Score with Your Physicians? Don’t Miss MIPS

Tue, 13 Feb 2024 10:00:00 -0500

The Merit-based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments. So, what’s the score for your physicians? Do they know?

During the next live edition of the long-running Monitor Mondays, Leigh Poland, vice president of coding services for AGS Health, will report on why it’s essential for all eligible clinicians to report their score to prevent a 9-percent downward adjustment for all Medicare Part B claims paid two years from the reporting year.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Kate Brantley, state legislative analyst for Zelis, will report on current healthcare legislation.

• Lead Story: Leigh Poland, vice president of coding for AGS Health, will report on the importance of physicians reporting their MIPS scores.

How CERT Data Is Used to Target Providers

Mon, 05 Feb 2024 13:00:00 -0500

Auditors use the Comprehensive Error Rate Testing (CERT) study from the Centers for Medicare & Medicaid Services (CMS) as a way to target individual providers for potential recoupment. For example, if you get paid millions of dollars for some procedure codes or DRGs that have high error rates, it increases the likelihood that those specific codes and/or DRGs will be audited. Why? Because, statistically speaking, whatever the error rate reported by CERT is can help estimate the potential improper payments made to a given provider and/or organization.

During the next live edition of the venerable Monitor Monday broadcast, senor healthcare analyst Frank Cohen will return to continue his series on CERT.

Broadcast segments will include these instantly recognizable features:

•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

•Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

•Lead Story: Senior healthcare analyst Frank Cohen will continue with his reporting on the CMS program CERT.

How to Protect Your Facility from CERT Audits

Mon, 29 Jan 2024 14:00:00 -0500

What’s important to know about the Comprehensive Error Rate Testing (CERT) program from the Centers for Medicare & Medicaid Services (CMS) is that auditors rely upon the results to target specific providers for recoupment audits.

The more you know about CERT and the study results, the better position you will be in when it comes to understanding both the general risk of an audit and the specific areas that might be at risk within your organization, according to senior healthcare analyst Frank Cohen. Cohen, long associated with Monitor Mondays, will return to the famed weekly Internet broadcast this coming Monday to begin a series on CERT: the Good, the Bad, and the Ugly.

Broadcast segments will include these instantly recognizable features:

•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

•Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.

•Lead Story: Senior healthcare analyst Frank Cohen will return to Monitor Mondays to begin a new series on the CMS program CERT.

U.S. Forced to Comply with International Healthcare Law: Fact or Fiction?

Mon, 22 Jan 2024 11:00:00 -0500

Will the World Health Organization (WHO) be given the power to impose restrictive pandemic measures on countries, including the United States? Will it be legally binding? What are the challenges and opportunities for healthcare providers in the United States, and how will this be enforced?

The member states of the WHO have been working on a plan of action when faced with the next pandemic. Negotiations are underway now, and their outcome will be submitted to the 77th WHO Assembly in May.

RACmonitor investigative Edward M. Roche will report the latest on this possible international compliance issue during the next live edition of Monitor Monday.

Broadcast segments will include these instantly recognizable features:

· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

· The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.

· Legislative Update: Cate Brantley, state legislative analyst for Zelis, will report on current healthcare legislation.

· Lead Story: RACmonitor investigative reporter Ed Roche will report on potential international compliance rules in the event of another global pandemic.

Look Out, Look Ahead

Mon, 08 Jan 2024 14:00:00 -0500

No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual.

As the rest of the nation’s healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here and in RACmonitor.

Broadcast segments will include these instantly recognizable features:

·Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

·The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.

· Home Care and Hospice: William Dombi, president and CEO for the National Association for Home Care and Hospice, will report on the latest news concerning Medicare home health and hospice but also Medicaid’s Home & community-based services (HCBS).

·Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

·Docs and Regs: Monitor Mondays’ own physician and attorney, Dr. John K. Hall, will report on the impact of artificial intelligence on healthcare.

· Tech Report: RACmonitor investigative reporter Edward M. Roche will report on the latest technology trends impacting America’s healthcare delivery system.

· Lead Story: Frank Cohen, founder of the Frank Cohen Group will report on his recent study about how major changes to the 2021 evaluation and management (E&M) services is impacting 2024 E&M coding and compliance.

2023 Healthcare Heroes to be Revealed

Mon, 04 Dec 2023 13:00:00 -0500

“He’s making a list, checking it twice…”

Calling them “Hirsch’s Heroes,” an annual tradition that began in 2015, Hirsch will reveal those to whom he has bestowed the esteemed honor during the next live edition of Monitor Mondays. So far, 15 distinguished individuals have been named “Hirsch’s Heroes.” This year, the loquatious Hirsch will only say for now that the 2023 heroes will be a physician, an attorney, and two revenue cycle professionals.

Other broadcast segments will include these instantly recognizable features:

· The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

· Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

· Legislative Update: Cate Brantley, state leglistative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

America’s Healthcare System: A Gordian Knot

Mon, 27 Nov 2023 12:00:00 -0500

RACmonitor investigative reporter Edward M. Roche, an intrepid regular monitor of America’s healthcare system, will return to Monitor Mondays for its next upcoming edition to report on how and why America’s healthcare system has tied itself into a Gordian Knot of complexity: interwoven strands of conflicting rules and regulations, different payments for the same services, and a cumbersome patchwork quilt of facilities, big, small, and smaller. Roche, who recently introduced to Monitor Mondays listeners the concept of “smart hospitals,” will also take a stab at answering a key question: just how smart are they?

Other broadcast segments will include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief leglistative affairs analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

At the Intersection of AI and Medical Record Audits

Mon, 20 Nov 2023 13:00:00 -0500

The annual 2023 MDaudit Benchmark Report has been published, and it is relevatory in its analysis of articial intelligence (AI) and its impact on payment and revenue integrity. According to the report, the primary topic of discussion for the next live edition of the long-running Monitor Mondays Internet broadcast, the implications of AI are immense when predicting its application to audit workflows – which is expected to impact outcomes for both providers and payers.

MDaudit CEO Ritesh Ramesh will appear as the special guest on Monitor Mondays to discuss the latest findings from the annual survey and how AI may impact healthcare revenue, including external payer audits and the detection of compliance and payment risks.

Other broadcast segments will include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, federal analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

False Claims Act Roundup: 2023 Was a Very Good Year for the Feds

Mon, 13 Nov 2023 17:00:00 -0500

To quote the titular lyrics of the song popularized by Frank Sinatra for his very first No. 1 hit, “it was a very good year.”

The U.S. Department of Justice (DOJ) announced that more than $2 billion in False Claims Act settlements and judgments were reported in the 2023 fiscal year.

According to the DOJ, government and whistleblowers were “party to 351 settlements and judgments,” the second-highest number ever recorded in a single year.

Providing a roundup of those settlements and judgments during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, a popular and respected correspondent.

Of note, more than $1.7 billion of that 2 billion were matters pertaining to the healthcare industry.

What can you do to protect yourself and your facility from the possibility of violating the False Claims Act? Listen to the next live edition of Monitor Mondays to find out.

Other broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, state legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

The Two-Midnight Rule Remains Too Confounding

Mon, 06 Nov 2023 11:00:00 -0500

The Two-Midnight Rule was first announced 10 years ago, October 2013, by the Centers for Medicare & Medicaid Services (CMS). Even today, though, the Rule remains an ongoing source of confusion for physicians as well as revenue cycle and finance experts.

However, it also will take on new importance, as CMS promises that Medicare Advantage (MA) plans will begin to follow the Rule in 2024.

During the next live edition of the popular and long-running Internet broadcast Monitor Mondays, physician and attorney Dr. John K. Hall will summarize the current state of the Two-Midnight Rule and offer insights of its use into the next decade.

Other broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The Whistleblower Report: Famed whistleblower attorney Mary Inman, partner in the law offices of Constantine Cannon, will report on the latest news concerning whistleblowers.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Violence in America’s Hospitals

Mon, 30 Oct 2023 12:00:00 -0400

Violence in America’s hospitals is an issue that is squarely on the minds of hospital administrators and staff. And the violence seen in our society has increasingly encroached into the medical workplace. This violence can be verbal, it can be physical, it can be disturbing, and it can be deadly. The escalation and prevalence of violence in hospitals has had a major impact on employees, patients, and families.

During the next live edition of Monitor Mondays, senior healthcare executive Dennis Jones will report on new regulatory initiatives, individual hospital actions, and one sweeping policy by a state hospital association – all aimed at making hospitals safer places to work.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brandley, state legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Lowering Prices, Increasing Supplies of Prescription Drugs

Mon, 23 Oct 2023 14:00:00 -0400

Congress and the Biden Administration continue to take a keen interest in issues related to prescription drug access and pricing. There is evidence of recent movement on Capitol Hill toward legislation aimed at addressing drug shortages affecting the healthcare system.

The government also is implementing a plan Congress approved last year to lower the prices Medicare will pay for certain drugs. For an exclusive update, register now to listen to the next edition of Monitor Mondays, when Maureen Testoni, president and CEO of 340B Health, will report on some of the latest Washington developments on these issues, including how they might affect the safety-net hospitals that deliver many of these drugs to patients.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

When it Rains, it Pours: Understanding New Compliance Risks

Mon, 16 Oct 2023 11:00:00 -0400

So far in October, the U.S. Department of Justice (DOJ) has been very busy, securing settlements, pleas, and convictions ranging in value from $25 to $350 million.

And just this month, DOJ announcements have featured settlements related to Anti-Kickback and Stark violations, as well as convictions in genetic testing schemes and guilty pleas for fraud involving unnecessary testing.

During the next live edition of Monitor Mondays, RACmonitor’s own physician and attorney, Dr. John K. Hall, will break down some of these recent reports to give you additional insights and help you understand your own risk.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

The Future of Cancer Treatment is Now: But Will Payers Pay?

Mon, 09 Oct 2023 13:00:00 -0400

Coinciding with National Breast Cancer Awareness Month (October), RACmonitor investigative reporter Edward M. Roche recently went to the laboratories of Memorial Sloan Kettering to investigate one of the most exciting scientific developments of the decade.

Roche, who was among the first to introduce the healthcare compliance world to algorithms, artificial intelligence (AI), and “smart” hospitals, said that the molecular biological approach to cancer treatment represents a true scientific breakthrough. He also recounted the three standard treatment stages in America’s efforts to combat breast cancer: surgery, radiation, and chemotherapy. Each of these treatments, according to Roche, can have substantial and sometimes devastating side effects. Now, developments in molecular biology carry the potential to sweep away these approaches and leave patients healthy with a bare minimum of discomfort. But the question remains: when all is said and done, will America’s healthcare insurance companies reimburse providers for these services?

Roche will outline these issues as the featured guest during the next live edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Does the Two-Midnight Rule Apply to MA Plans?

Mon, 02 Oct 2023 12:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) is on record saying that Medicare Advantage (MA) payers must follow the Two-Midnight Rule as of Jan. 1, 2024. Yet, it has been reported by multiple hospitals that their MA plans have said their lawyers tell them that they do not have to follow the CMS directions on the Rule relative to inpatient status, claiming their contracts govern their relationships and coverage issues with hospitals.

During the next live edition of Monitor Mondays, Dennis Jones, senior director of revenue cycle (a single business office) for Jefferson Health, will report on the arguments that seem to be iginiting a firestorm on the Internet.

Broadcast segments will include these instantly recognizable features:

• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, state legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Peeking Behind the Curtain: AI and Claims Auditing

Mon, 25 Sep 2023 12:00:00 -0400

It’s little wonder that we will be reporting on artificial intelligence (AI)during the next live edition of Monitor Mondays. We were among the first to report on algorithms in claims auditing.

But now, with so much attention being paid by the general news media to AI, its role in healthcare is gaining even greater attention and traction. So, during next live edition of our weekly Internet radio broadcast, we will take a deep dive into the role of AI and its use in auditing medical claims for accuracy and compliance when Blake Wylie, chief technical officer for Clarity Ventures Group, joins the broadcast.

By utilizing machine learning algorithms, auditors can sift through vast amounts of data to identify discrepancies and errors, thereby enhancing the overall reliability and efficiency of the medical billing process.

Broadcast segments will include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney Geoffrey Koslig, associated with law offices of Fredrikson & Byron, will substitute for David Glaser, to share his perspective on business issues that might appear (and in many cases, actually are) quite risky.
Special Report: Govind Goyal, president of financial services for Panacea Healthcare Solutions, will report on the latest news about the beleaguered Hospital Price Transparency rule.
Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.
Lead Story: RACmonitor investigative reporter Edward M. Roche will report the lead story on the performance scorecard for Medicare.

The Medicare Report Card: Assessing Areas for Major Reform

Mon, 18 Sep 2023 13:00:00 -0400

The United States spends more money on healthcare than any other country in the world. In 2021, U.S. healthcare spending reached $4.3 trillion.

Medicare, which insures seniors, is America’s largest national health program, and therefore, it can and should be compared to its counterpart in other countries. So, how does the United States stack up?

How do outcomes in the United States compare for patients, and what kind of comparisons can we make from the point of view of the healthcare provider? Do doctors have it better in the United States, or in other places? What lessons can we learn? Where are the most urgent areas that need reform?

During the next live edition of Monitor Mondays, RACmonitor investigative reporter Edward M. Roche will examine U.S. healthcare in comparison with that of other countries, focusing on a number of dimensions, including cost, quality, outcomes, and ease of use.

Broadcast segments will include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Lead Story: RACmonitor investigative reporter Edward M. Roche will report the lead story on the performance scorecard for Medicare.

Like Autumn Leaves, RAC Audits Keep Falling

Mon, 11 Sep 2023 13:00:00 -0400

The fall season is just about here. Colorful autumn leaves will be becoming ubiquitous, like claims denials and audits. And in this season, now is the time to “git ‘er done.”

And Monitor Mondays is the place to do it.

In preparation, following the long Labor Day weekend, RACmonitor producers of Monitor Mondays have enlisted the services of some of the most trusted and respected names in regulatory compliance and claims auditing. And joining this panel of experts in the long-running Internet broadcast will be a new voice added to the lineup: Angela Jordan, currently executive vice president of Calm Waters AI, Inc., specialists in evaluation and management (E&M) leveling services.

Broadcast segments will include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on the latest legislative actions that will impact the healthcare regulatory setting.
E&M Update: Angela Jordan, executive vice president for Calm Waters AI, Inc., will report on the latest twists and turns associated with the omnipresent E&M services impacting physicians and physician groups.

Assessing the Impact of Financial Woes Facing America’s Healthcare Providers

Mon, 28 Aug 2023 12:00:00 -0400

First there was COVID-19, which seemed to have torn a gaping hole in our nation’s patchwork quilt of care facilities. Add to this the rising costs of everything that touches healthcare, and now the growing list of Chapter 11 bankruptcies rippling through nursing homes and other facilities that provide care for America’s seniors.

But will the tentacles of this lengthening financial crisis reach down and strike at other similar facilities? Reporting our lead story during the next live edition or Monitor Mondays will be William Dombi, president and CEO for the National Association for Home Care and Hospice.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Physician Advisors: Revenue Drag or Stimulant?

Mon, 21 Aug 2023 13:00:00 -0400

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

What’s So Smart About Smart Hospitals?

Mon, 14 Aug 2023 16:00:00 -0400

Information technology has revolutionized many industries, including healthcare. “Smart” hospitals promise vast increases in productivity, and are being designed as integrated IT platforms linking together technology, patients, and providers in a complex web of interaction.

But are the promised advantages of smart hospitals tangible, or are there a number of factors that may inhibit providers from obtaining the benefits that are promised? And how are things really measured? Edward M. Roche will discuss this high-growth area of expenditures, and go over both the accelerators and inhibitors of this transformation in healthcare.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.

FY 2024 IPPS Final Rule: Looking Under the Hood for Hazards

Mon, 07 Aug 2023 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) FY2024 Inpatient Prospective Payment System (IPPS) Final Rule, posted on Aug. 1, reveals changes to the MS-DRG, CMS Hospital Acquired Conditions, and CMS Inpatient Quality Reporting Program affecting inpatient revenue cycles, quality reporting, and reputations essential to hospital operations. There are plenty of audit hazards. And that’s why RACmonitor invited James S. Kennedy, MD, a nationally recognized clinical coding authority, to be our expert tour guide during the next live edition of Monitor Mondays to identify potential risks and opportunities effective on October 1, 2023.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Cara Ludwig, substituting for Knicole Emanuel, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.

Proposed Expansion of Medicaid RACs Includes Focus on Managed Care Payments

Mon, 31 Jul 2023 13:00:00 -0400

The Government Accountability Office (GAO) is recommending expansion of the Medicaid Recovery Audit Contractors (RACs) program, to include auditing of payments made to managed care organizations (MCOs), according to a GAO report released in June.

Launched in 2011 as a consequence of the Patient Protection and Affordable Care Act (PPACA) by the Centers for Medicare & Medicaid Services (CMS), the Medicaid RACs were purported to be aggressive in their recouping of alleged Medicare Fee-for-Service (FFS) overpayments. They could now be poised to expand into the rapidly growing MCO plans.

During the next live edition of Monitor Mondays, Dennis R. Jones, senior director of revenue cycle at Jefferson Health, will report on this developing story.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

New Developments for Defeating Statistical Extrapolations Revealed

Tue, 25 Jul 2023 11:00:00 -0400

There is a buzz swirling within the healthcare auditing community. And thanks to RACmonitor investigative reporter Edward M. Roche, the news is buzzworthy.

According to Roche, a legal team has developed two arguments that can be used by healthcare providers in federal court after the Administrative Law Judge (ALJ) process is completed. One argument is based on constitutional rights, while the other is a contradiction between the Medicare Program Integrity Manual and adopted federal law.

During the next live edition of Monitor Mondays, Mr. Roche will discuss these two arguments briefly, and issue a call for providers who are at this stage in their appeals and might be interested in someone taking up their case on a contingency basis.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, state legislative affairs analysis for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

$9 Billion Refund to 340B Hospitals at Risk

Mon, 17 Jul 2023 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to remedy Medicare Part B pay cuts made to 340B hospitals by issuing a lump-sum repayment to affected facilities.

Last year, the U.S. Supreme Court ruled that those cuts, implemented by CMS from 2018 through most of 2022, were unlawful. Consequently, CMS proposed to offset the refunds by reducing payments for non-drug services to all hospitals under the 2024 Outpatient Prospective Payment System (OPPS). Commenting on this latest development impacting 340B hospitals during the next edition of Monitor Mondays will be the president and CEO for 340B Health, Maureen Testoni.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analysis for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Enforcement and Penalties, Guardrails and Risks: Understanding the 21st Century Cures Act

Mon, 10 Jul 2023 13:00:00 -0400

Although the 21st Century Cures Act was enacted in 2016, many hospitals today continue to struggle with effective implementation of its provisions and the goal of preserving patient access to medical records.

Seven years later, however, meaningful guidance regarding its enforcement is here. One of the provisions requires developers not to engage in information blocking.

Now that the guardrails are in place and the risks have been identified, Monitor Monday’s own physician and attorney Dr. John K. Hall will review the related enforcement actions and the penalties during the next live edition of the long-running Internet broadcast.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.

The Big Worry. The Big Unwind: Medicaid Disenrollment Keeps Rolling Along

Mon, 26 Jun 2023 14:00:00 -0400

At least 1.3 million Medicaid enrollees have been disenrolled as of June 20, according to the Kaiser Family Foudation (KFF) “Unwinding Tracker.” This estimate could be an under-count, KFF admits, due to state recordkeeping details. Yet the major issue looms on the horizon: what will happen to those who have lost their Medicaid benefits? Could a tsuansmi of patients without health insurance soon appear at your hospital?

During the next live edition of Monitor Mondays, Tony DiLuca, principal at Physician and Tactical Healthcare Services, LLC (PATHS) and a member of the Pennsylvania Department of Health and Human Services (HHS) Fee-for-Service Subcommittee, will report on the unwinding process of the enrollment, along with current updates and best practices.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

How Suffocating Regulations Are Leading to Smart Hospitals

Mon, 19 Jun 2023 12:00:00 -0400

“Hospitals may be the most complex organizations in the world,” writes Edward M. Roche, scholar, United Nations consultant, and RACmonitor investigative reporter. “They are tasked with improving patient outcomes, controlling costs, and meeting sustainable environmental goals.”

Roche, who will be the featured panelist during the next live edition of Monitor Mondays, believes that hospitals, in their quest for stability, have been nonetheless traumatized by the COVID-19 epidemic and a suffocating regulatory environment. Roche will also report on how many American hospitals now are in the midst of a digital transformation that is leading to an era of “smart hospitals” that will deliver unparalleled integration and improvements in all aspects of healthcare.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

How Staffing Shortages Increase Audits

Mon, 12 Jun 2023 13:00:00 -0400

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare & Medicaid Services (CMS), U.S. Department of Justice (DOJ), and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) have increased audits to reduce improper payments, using predictive modeling and artificial-intelligence (AI) tools. Risk-based audits rose by 28 percent and prospective audits by 32 percent in 2022.

To ease the burden on revenue cycle management (RCM) teams, a combination of automation, analytics tools, and denial management software can be used for hybrid audits, reducing denials and increasing reimbursements. During the next live edition of Monitor Mondays, Ritesh Ramesh, CEO for MDaudits, will report on how, by leveraging people and technology, internal audits can be conducted faster, errors caught earlier, and staff can focus more on training and optimizing revenue.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
The RAC Report: Healthcare attorney Kyla Wonder, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Running Afoul of Federal Regulations

Mon, 05 Jun 2023 13:00:00 -0400

This week, a disgraced Elizabeth Holmes was seen in media clips walking in the company of two unidentified men. Evidently, Holmes, who was convicted of fraud for her blood-testing start up, Theranos, turned herself in at a minimum-security prison in Texas to begin an 11-year prison term.

All this media coverage raises the question: how easy is it to run afoul of the government regarding a wide range of statutes and regulations?

Moreover, how far do you have to go to actually get to prison? During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine some recent convictions and sentences to help you assess your risk – keeping in mind that there’s no parole from federal prison.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Bonney Olney, director of Level of Care Service for R1 RCM, will make her Monday rounds, substituting for Dr. Ronald Hirsch.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, JD, a legislative analyst for Zelis, will report on current healthcare legislation.

Smart Strategies to Avoid Denials of SNF Transfers

Mon, 22 May 2023 14:00:00 -0400

Why the confusion and the apparent uptick in denials by Managed Care Organizations (MCOs) for skilled nursing facility (SNF) transfers?

Returning to report on this vexing topic during the next live edition of Monitor Mondays will be Ben Kartchner, MD, a physician advisor who will join the broadcast to present the final installment in his two-part series being produced by RACmonitor and Monitor Mondays.

Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors, exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Mary Beth Pace, vice president of Trinity Health, will be making her Monday Rounds, substituting for Dr. Ronald Hirsch.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

How to Avoid Managed Care Denials for SNF Transfers

Mon, 15 May 2023 12:00:00 -0400

Medical necessity denials for skilled nursing facility (SNF) transfers by Managed Care Organizations (MCOs) are increasing at an astonishing rate.

The reason seems to be a lack of understanding of the difference between skilled and non-skilled care. During an exclusive two-part series being produced by RACmonitor and Monitor Mondays, Ben Kartchner, MD will delve into this complex topic that is generating buzz, especially among physician advisors, many of whom appear to be struggling with post-acute care (PAC) and, specifically, SNF services. In fact, Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Compliance Risk and Revenue Loss: Practicing without Privileges

Mon, 08 May 2023 13:00:00 -0400

Your medical staff office just notified you that a physician has been performing procedures without privileges for the past five years.

No, it doesn’t happen all the time. But what should you do?

Physician and attorney Dr. John K. Hall will walk you through the considerations and help you understand how much revenue might be in jeopardy during the next live edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Utilization and Billing: Reconciling Conflicts

Mon, 01 May 2023 13:00:00 -0400

Hospital utilization and billing are notoriously challenging concepts for providers and case management staff because they frequently boil down to two, often conflicting points of view: what can be done per the rules, regulations, and contracts, and what should be done to provide the most effective care for a patient? In a world where process standardization is imperative to maintain health system viability, but also where the practice of medicine remains an art, teams need a broad understanding of medical necessity and billing rules.

Join us during the next live edition of Monitor Mondays when Dr. Juliet B. Ugarte Hopkins reports on where you can give and take and how to parse out the varying shades of grey.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

The False Claims Act: Will it Live to See Another Day?

Mon, 24 Apr 2023 13:00:00 -0400

The beleaguered False Claims Act, which traces its origins to the Civil War, came before the Supreme Court this past Tuesday, when the Court heard oral arguments in a consequential and closely watched case involving one of the Government’s most effective tools for fighting healthcare fraud.

Specifically, the issue is whether and when a defendant’s contemporaneous subjective understanding or beliefs about the lawfulness of its conduct are relevant to whether it knowingly violated the Act. This case involves accusations that supermarket pharmacies Safeway and SuperValu overcharged Medicare and Medicaid for generic drugs by misrepresenting the usual and customary prices they charged for the drugs.

During the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at the law offices of Constantine Cannon, will provide background and context on the case that the Court is expected to issue a ruling for in June, at the end of its term.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Confronting Artificial Intelligence: Healthcare’s Next Major Disruptor

Mon, 17 Apr 2023 12:00:00 -0400

Recent highly publicized advances in artificial intelligence forecast the elimination of at least 30 percent of the healthcare workforce (probably more), including all generalist physicians. The astonishing scalability of information technology suggests that one to three data centers will be able to deliver medical advisory services to the entire population of the United States, according to Edward M. Roche, who will be reporting our lead story during the next live edition of Monitor Mondays.

Roche is expected to report that as a country, America will see the debilitating cost of much healthcare being delivered today reduced to pennies and for all practical purposes delivered free of charge. But, cautions, Roche, such a game-changer will not be put in place without much resistance. So, who will be the winners and the losers in this new era of AI-driven healthcare? Register now to listen Monday.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Dr. James Kennedy, President of CDIMD, will be making his Monday Rounds, substituting for Dr. Ronald Hirsch.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

The Ins and Outs of Procedures: Confronting the CMS Inpatient-Only List

Mon, 10 Apr 2023 14:00:00 -0400

This year, as in past years, the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only List continues to confuse and bewilder so many healthcare professionals. And it’s little wonder: in 2021, CMS removed 500 surgical procedures from the List, only to reinstate most but not all of the procedures for 2022. Today, most Medicare and Medicaid plans follow the CMS Inpatient-Only List. But not all.

Join us this coming Monday when Mary Beth Pace, our special guest on the next edition of Monitor Mondays, will serve as our guide, helping you avoid auditing pitfalls while traversing this tricky compliance territory of inpatient versus outpatient status.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Reintroducing the Three-Midnight Rule: It’s Back, and it’s a Problem

Mon, 03 Apr 2023 13:00:00 -0400

It’s back: the Three-Midnight Rule.

Created with the nation’s 1965 enactment of Medicare, the Rule provided that patients needed to have at least three consecutive midnights of inpatient care in an acute hospital setting before being admitted to skilled nursing facility (SNF). And then came the COVID-19 pandemic and the federal Public Health Emergency (PHE), and the rule was waived.

Now, as the PHE is about to expire on May 11, the Rule is making a comeback. And that could pose problems for thousands of case and utilization managers across the country who are either out of practice with managing this Medicare requirement or have never in their careers had to address it.

Join us during the next live edition of Monitor Mondays, when Juliet B. Ugarte Hopkins, MD, president of the American College of Physician Advisors, will be reporting on this new regulatory challenge and how to avoid the pitfalls associated with the inevitable audits that are likely to ensue.

Broadcast segments will also include these instantly recognizable features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

15 Million Enrollees Soon to be Missing: The Unwinding of Medicaid’s Continuous Enrollment

Mon, 27 Mar 2023 12:00:00 -0400

It’s the biggest healthcare story of the decade: up to 15 million individuals will soon be disenrolled from Medicaid, when the COVID-19 public health emergency (PHE) shuts down. Those who enrolled in Medicaid during the pandemic must re-enroll to keep their Medicaid coverage. Suddenly, your hospital could be overrun with uninsured patients.

What’s being done about this issue, and what can you do?

Join us during the next live edition of Monitor Mondays, when Dennis Jones will be reporting on the unwinding of the Medicaid Continuous Enrollment Provision of the Public Health Emergency (PHE).

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Reverse False Claims: This Could Happen to You

Mon, 20 Mar 2023 15:00:00 -0400

Imagine for a moment that the federal government, through one of its contractors, sends you money for services you don’t believe are covered benefits for a particular patient at your facility.

But wait. Don’t react just yet.

The best course of action might not be what you think, and it’s definitely not simple or straightforward, as you’ll learn during the next live edition of the long-running Monitor Mondays Internet radio broadcast. That’s when physician and attorney Dr. John K. Hall will explore the mysteries of Advance Beneficiary Notices (ABNs) and reverse false claims.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

The Anatomy of Fraud: Kickbacks and 64,000 False Claims

Mon, 13 Mar 2023 13:00:00 -0400

Famed whistleblower attorney Mary Inman will return to the Monitor Mondays weekly Internet radio broadcast this coming Monday to report on a unique case in which a jury found that Precision Lens and its owner, Paul Ehlen, illegally paid kickbacks to ophthalmic surgeons to induce their use of the company’s products in cataract surgeries reimbursed by Medicare.

The company was found to have submitted more than 64,000 false claims to Medicare, costing the program about $43 million in single damages. Precision Lens was found to have violated both the Anti-kickback Statute and the False Claims Act, which allows private individuals like the whistleblower in this case to sue in the name of the United States, alleging that the federal government has been defrauded.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

National Doctors Day Recognizes Physicians as Gatekeepers

Mon, 06 Mar 2023 13:00:00 -0500

We at Monitor Mondays will begin a monthlong observance of National Doctors’ Day this coming Monday, March 6.

Although the 90-year-old recognition of American physicians is March 30, during the next live edition of our weekly Internet radio broadcast we will recognize the contributions of Scott Ceule, MD, a physician advisor who, along with his team, helped create a transfer center at the University of Kansas Health System.

Dr. Ceule will report on the process of creating a transfer center, while explaining the role of physician advisors in the transfer process; they are akin to gatekeepers in that they allow an organization to evaluate medical necessity, financials, and utilization review prior to accepting patients to the acute-care setting.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

FCA Fraud Against U.S. Tops $2.2 Billion

Mon, 27 Feb 2023 12:00:00 -0500

The U.S. Department of Justice (DOJ) reports that fraud against the U.S. under the federal False Claims Act (FCA) has amounted to $2.2 billion recovered in settlements and judgments for the 2022 fiscal year.

As in past years, FCA recoveries in the healthcare and life sciences industries continued to dominate enforcement activity in terms of the number and value of settlements, with healthcare fraud cases comprising 80 percent of total recoveries. These involved a wide range of issues, including Medicaid fraud, unnecessary and substandard care, kickbacks, and Medicare Advantage (MA) fraud.

During the next edition of the weekly Internet radio broadcast, whistleblower attorney and Monitor Mondays regular contributor and panelist Mary Inman will report on healthcare enforcement trends from 2022, including a record-breaking $266.4 million reward to the whistleblower who reached a $900 million settlement with Biogen for kickback allegations, 10 years after filing his qui tam case.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Crossing the Compliance Line: Worth Less or Worthless?

Mon, 20 Feb 2023 12:00:00 -0500

The concern is real. And it’s growing.

Providers could incur False Claims Act (FCA) liability when care that is delivered crosses over from “worth less” to “worthless.” You need to know where to draw the line. And that’s why we asked physician and attorney John K. Hall to explain, during the next live edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

Special Report: Prominent healthcare attorney Andrew Wachler, managing partner at Wachler and Associates, will return to the broadcast to report on meeting the 90-day statutory timeframe for administrative law judge (ALJ) hearings.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

To Be, Or Not to Be: Reconciling Inpatient Status

Mon, 13 Feb 2023 16:00:00 -0500

What constitutes inpatient status? Should patient status be determined by guidelines or screening criteria? Or just the facts?

Revisiting what is certain to be considered an evergreen issue, Dr. Andrew Markiewitz will return to report the lead story for the next upcoming live edition of Monitor Mondays to continue discussing the vexing topic of patient status. Dr. Markiewitz is expected to report that screening criteria, scoring systems, and guidelines help determine medical necessity and patient status. But, he will add, although these metrics are used by payers, they are not treatment protocols. “We need to base our care on the patient in front of us,” advises Dr. Markiewitz.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Folana Houston, a legislative analyst for Zelis, will report on current healthcare legislation.
The Wrapper: Dr. John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

The Nationwide Audit News Roundup

Mon, 06 Feb 2023 14:00:00 -0500

Healthcare providers nationwide are facing menacing interactions with auditors that, like hungry predators, are looking at submitted claims for the slightest evidence of omission or commission as the justification to pounce.

But it’s not so much the actual auditing as the long and wearisome journey of appeals – and the very real possibility of financial disaster. Although medical record auditing is not new, its frequency and alleged abuses contribute to a tell a tale of tragedy for America’s healthcare system.

That is why each and every Monday morning, Monitor Mondays has been alerting its listeners as to consequences of auditing gone awry – but also reporting on preventative measures providers can take to help their facilities avoid takebacks and fines.

This coming Monday, Monitor Mondays will continue with its reporting on auditors behaving badly.

That’s when listeners will hear of complication and comorbidity (CC) risk scores: a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care.

Out of this model was born clinical documentation improvement, or CDI – a push to improve documentation so that it improves the reporting of diagnoses and procedures, thereby optimizing the scores. But with this comes the opportunity for abuse.

So, can these risk scores help predict whether a provider is under-coding, over-coding, or coding optimally?

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.
The Cohen Report: Senior healthcare analyst Frank Cohen will file the second report in his two-part series on his research findings that Hierarchical Condition Category (HCC) risk scores could be used to negotiate Medicare Advantage rates.
Livestream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Mary's Bookclub: Respiratory Therapy All Access Pass

Wed, 01 Feb 2023 14:00:00 -0500

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore!

In this episode, Mary goes over the Respiratory Therapy All Access Pass, and why it is an important product for healthcare professionals.

Exclusive: Never-Before-Released HCC Data Reveals Possible Link to Under/Over Coding

Mon, 30 Jan 2023 15:00:00 -0500

Never-before-seen data has revealed that Hierarchical Condition Category (HCC) risk scores could predict under- or over-coding – and it will be the primary topic of discussion during the next live edition of Monitor Mondays.

That’s when senior healthcare analyst Frank Cohen will report on his findings. The HCC risk score is a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care.

So, can the HCC risk score help predict whether a provider is under-coding, over-coding, or coding optimally?

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.
Livestream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Do No Harm: A Quarter of Medicare Patients Experience Adverse Events, per the OIG

Mon, 23 Jan 2023 13:00:00 -0500

In May 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a report claiming that 25 percent of Medicare patients experienced adverse events during their October 2008 hospital stay.

“That’s a staggering number,” said John K. Hall, MD, in an email to RACmonitor. “So, what does it mean, and what should providers expect from other auditors and government agencies?”

During the next live edition of Monitor Mondays, physician and attorney Dr. Hall will review the report and offer suggestions to prepare if the OIG comes knocking at your door.

Broadcast segments will also include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
LiveStream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Mary's Bookclub: Nuclear Medicine All Access Pass

Thu, 12 Jan 2023 10:00:00 -0500

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore!

In this episode, Mary goes over the Nuclear Medicine All Access Pass, and why it is an important product for healthcare professionals.

Nationwide Dragnet: An Update on Auditing

Mon, 09 Jan 2023 14:00:00 -0500

No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual.

Broadcast segments will include these instantly recognizable features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds, during which he will report an exclusive auditing story in which he details news about a move by the Centers for Medicare & Medicaid Services (CMS) to clamp down on Medicare Advantage (MA).
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Legislative Update: Cate Brantley, a federal legislative analyst for Zelis, will report on current healthcare legislation.
Docs and Regs: Monitor Mondays’ own physician and attorney, Dr. John K. Hall, will report on how revisions to water down the Medicare Program Integrity Manual tend to increase liability for providers.
Tip Sheet: RACmonitor investigative reporter Edward M. Roche will have another jaw-dropping story about audits, auditing, and a dismal outlook for 2023.
Live Stream Chatting: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Mary's Bookclub: Infusion & Injection All Access Pass

Wed, 14 Dec 2022 10:00:00 -0500

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore!

In this episode, Mary goes over the Infusion & Injection All Access Pass, and why it is an important product for healthcare professionals.

Too Big to Fail: Part II

Mon, 12 Dec 2022 14:00:00 -0500

In October, after 18 months in the news cycle, Optum closed its controversial acquisition of Change Healthcare. While the healthcare industry intensely watched the merger beat a challenge from the U.S. Department of Justice (DOJ) on antitrust grounds, that news story was far from the only newsworthy acquisition that Optum has made. With far less public discourse than the Change Healthcare acquisition, Optum has made 18 acquisitions and six investments in recent years. The company has spent more than $30 billion on acquisitions in multiple sectors.

Simply stated, Optum is embedded in every nook and cranny of healthcare and is the keeper of big data and analytics for employers, health plans, state and federal agencies and providers. So the question remains: Too big to fail? Reporting our lead story during the next live edition of Monitor Mondays will be Jerilyn Morrissey, MD, senior vice president of clinical and regulator affairs for Versalus Health.

Other segments will include these instantly recognizable broadcast features:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds during time he will unveil his noteworthy 2022 “Hirsch’s Heroes,” which debuted here on Monitor Monday in 2016. Hirsch’s Heroes recognizes healthcare professionals who made a difference in healthcare. The awards are returning this year after a two year hiatus during which every front line health care worker was a hero.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Legislative Update: Adam Brenman, a federal legislative analyst for Zelis, will report on current healthcare legislation.

Medicare Audits: The Hunting Game

Mon, 05 Dec 2022 13:00:00 -0500

Are Medicare auditors similar to ancient hunting parties roaming the tundra for wild game? Are audits applied equally and randomly across all healthcare providers, or is there intelligent design directed by a hidden network of influencers, working behind the scenes and shifting first to one area, then another?

During the next live edition of Monitor Mondays, Edward M. Roche, RACmonitor’s investigative reporter, is going to look at the data to see if there are patterns in auditing and settlements – and if possible, identify the drivers behind these waves of aggressive activity.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Mary's Bookclub: Comprehensive Cardiology All Access Pass

Wed, 30 Nov 2022 09:00:00 -0500

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore!

In this episode, Mary goes over the Comprehensive Cardiology All Access Pass, and why it is an important product for healthcare professionals.

Eating Their Own: OIG Investigating Medicare Contractors and CMS

Mon, 28 Nov 2022 12:00:00 -0500

We’ve all watched in awe as the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) began investigating the Medicare Advantage plans. Many were thinking, “it’s about time the payers get some of the heat providers feel.” But there’s something even better, according to most. That’s when the OIG investigates the government.

During the next live edition of Monitor Mondays, physician-attorney Dr. John K. Hall reviews an OIG audit of Medicare contractors and the Centers for Medicare & Medicaid Services (CMS). He’ll also explain what this means for providers.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Swimming Among Sharks in a Sea of Turmoil: 2022 Audit Landscape

Mon, 21 Nov 2022 13:00:00 -0500

Most healthcare providers are swimming in shark-infested waters these days, ever-watchful for dorsal fins that signal imminent danger.

At first there were the Recovery Auditors (RAs), created by the Centers for Medicare & Medicaid Services (CMS), to correct Medicare billing submitted by providers for services rendered to Medicare beneficiaries. And now, nearly two decades later, the RAs have been joined by several other auditors, and healthcare has quickly become a dangerous and expensive environment, especially given a new breed of sharks: the Medicare Advantage Organizations (MAOs), whose primary mission is to save money by denying claims in the name of compliance.

Join us next Monday for another live edition of the long-running Monitor Mondays Internet broadcast for a news round-up, and to learn of more lurking dangers and how to protect your facility’s revenue while remaining compliant, even amid all the turmoil.

Other segments will include these instantly recognizable broadcast features:

OIG Report: Monitor Monday’s own physician and attorney, Dr. John K. Hall, will report on the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit of critical care billing at Leahy Clinic in Boston. If you have an ICU, you will need to hear his report.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Marie Stinebuck, COO of Phoenix Medical Management, Inc, will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Adam Brenman, Federal Legislative Analyst for Zelis, will report on current healthcare legislation.

Mary's Bookclub: Ultrasound Coder

Wed, 16 Nov 2022 11:00:00 -0500

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Ultrasound Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.

Winds of Change in the South: No Jubilee with Cotiviti

Mon, 14 Nov 2022 13:00:00 -0500

Along the gulf shores of Mobile Bay in Alabama, at the crack of dawn you might hear shouts of jubilation from early risers there to witness flounder, soft-shell blue crabs, and gulf shrimp beach themselves due to the upward movement of oxygen-deprived bottom waters. The aftermath is a bounty of seafood on the sandy beaches, and hence the local dish known as “jubilee.”

Yet when it comes to local healthcare providers dealing with the Recovery Auditor (RA) Cotiviti, there is no jubilance – as you will hear Jennifer Bartlett explain during the next live edition of Monitor Mondays. Bartlett will report on the difficulty she and her team, along with other providers, face as they cope with the vagaries of one of the largest of the RAs in the U.S.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

2023 Medicare Physician Fee Schedule Final Rule: Telehealth Services Post-COVID-19

Mon, 07 Nov 2022 13:00:00 -0500

The Medicare Physician Fee Schedule Final Rule for 2023 includes a provision for telehealth services – this following the temporary expansion of telehealth to beneficiaries during the COVID -19 public health emergency (PHE) that began March 1, 2020. Once the temporary PHE waivers terminate, what are the plans the Centers for Medicare & Medicaid Services (CMS) has for covering telehealth services for Medicare beneficiaries?

Join 3M consultant Colleen Deighan-Ejak during the next live edition of Monitor Mondays, when she will outline what is included in the Final Rule for Medicare telehealth services.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Collateral Consequences of Medicare Audits

Mon, 31 Oct 2022 13:00:00 -0400

Healthcare attorney Andrew Wachler is an audit warrior, with war stories that will make you cringe in absolute disbelief.

And during the next live edition of Monitor Mondays, Wachler will tell some of these stories, sharing lessons to learn from his experience defending provider clients. He’ll report how failure to appeal a target, probe and educate (TPE) audit could establish a “pattern or practice of submitting claims fail to meet Medicare requirements” for the purpose of revocation of Medicare billing privileges.

Wachler will also share challenges related to lifting a Medicare payment suspension implemented across multiple Medicare Administrative Contractor (MAC) jurisdictions.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Adam Brenman, a federal legislative analyst, will substitute for Matthew Albright to report on current healthcare legislation.

Exclusive Report: Winds of Change Blowing for Medicare Advantage Plans

Mon, 24 Oct 2022 13:00:00 -0400

Rumors, as they tend to sometimes, are spreading fast. Are there significant leadership changes coming within the largest Medicare Advantage (MA) plans for many beneficiaries in the mid-South region of the country?

Spend time with Jennifer Bartlett, longtime systems coordinator at Infirmary Health System in Mobile, Alabama, and it becomes clear that there could be a whole new ballgame, with new players. Are MA plans recalibrating their auditing approaches to providers? Could the payers be reacting to accountability tools?

Join us during the next live edition of Monitor Mondays, when Bartlett will report on her experience with Humana and UnitedHealthcare – and how her Audit Activity Reports are the best tool to have in your toolkit to level the playing field shared by facilities and these gargantuan MA plans.

Other segments will include these instantly recognizable broadcast features:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will substitute for Matthew Albright to report on current healthcare legislation.

The Tables Are Turning: OIG Sets Sights on Medicare Advantage DRG Validation Denials

Mon, 17 Oct 2022 13:00:00 -0400

DRG validation denials by Medicare Advantage (MA) plans have become a widespread and increasing concern for many hospitals.

But these denials may be the result of a misapplication of standard diagnostic criteria by a reviewer. Now, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is turning the DRG validation denials back on MAs. The OIG recently published several diagnosis-validation audits of MAs and recommended recoupment for exactly the same diagnoses the MAs have denied for providers.

But what can we learn from these audits to help manage diagnosis denials by payers? Does this portend new MA tactics? Sitting in for Dr. Ronald Hirsch during the next edition of Monitor Mondays will be our own physician and attorney, Dr John K. Hall, who will offer his take on the future of diagnosis denials and how to prepare.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors;
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment;
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH; and
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Mary's Bookclub: Nuclear Medicine & PET Coder

Wed, 12 Oct 2022 10:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Nuclear Medicine & PET Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.

Exclusive: Some Extrapolation Estimates Vacated

Mon, 10 Oct 2022 14:00:00 -0400

While the pandemic may have shielded healthcare providers from intrusive recoupment audits, the auditing break was but temporary. Starting in August of 2021, UPIC, TPE, RAC and other audits started back up and the contractors had a lot of catching up to do. At the same time, the administrative law judges were under enormous pressure to get the backlog of cases completed by the end of 2022. The result? A paradigm shift in how hearings were conducted and the impact that has on outcomes.

Senior healthcare analyst and RACmonitor correspondent Frank Cohen will talk about how these changes have benefited providers in getting judges to vacate the extrapolation estimates.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will substitute for Matthew Albright to report on current healthcare legislation.

False Claims Act: Biogen to Pay $900 Million: Whistleblower Gets $250 Million

Mon, 03 Oct 2022 13:00:00 -0400

According to the U.S. Department of Justice, pharmaceutical giant Biogen will pay $900 million to settle a lawsuit that alleged the company gave doctors kickbacks to encourage them prescribe its drugs. The settlement resolves a lawsuit filed and litigated by former Biogen employee Michael Bawduniak against Biogen under the qui tam or whistleblower provisions of the federal False Claims Act. Famed whistleblower Mary Inman will report this story during the next live edition of Monitor Mondays. Inman, reporting from her London office, is expected to provide details on the settlement.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, who will report on current healthcare legislation.

Beware: Enforcement of the Hospital Price Transparency Rule

Mon, 26 Sep 2022 14:00:00 -0400

Beware of enforcement action by the Centers for Medicare & Medicaid Services (CMS) for noncompliance of the Hospital Transparency Rule which took effect January 2021. The rule requires hospitals to make public—in machine readable files—prices for certain items and services. Failure to comply could result in fines as in the case of two Georgia hospitals. Make no mistake. CMS is laying down the law. Reporting our lead story during the next live edition of Monitor Mondays will be Govind Goyal, Executive Vice President at Panacea Healthcare Solutions, and a subject matter expert on Hospital Price Transparency Rule.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, who will report on current healthcare legislation.

Mary's Bookclub: CT/MR Coder

Wed, 21 Sep 2022 14:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of CT/MR Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.

Medicare: The New Drug Price Negotiator

Mon, 19 Sep 2022 12:00:00 -0400

Provisions in the newly enacted Inflation Reduction Act represent some of the most significant changes to the healthcare system that have taken effect in the past decade. Maureen Testoni, president and CEO of 340B Health, will review some of the new law’s drug pricing elements. They include provisions for Medicare to start negotiating the prices it will pay for certain drugs for the first time in the program’s history. How these drug pricing changes play out will affect the entire healthcare system, including the safety-net providers who already receive discounted prices on some prescription drugs.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
The News Report: Dennis Jones, Patient Financial Services at Montefiore Nyack Hospital will report on the single payer proposal.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, who will be substituting for Matthew Albright, will report on current healthcare legislation.

Medical Necessity: The Necessity of Defining the Dilemma

Mon, 12 Sep 2022 13:00:00 -0400

A national debate is raging across America involving providers and payers. The vexing issue is of medical necessity—and the search for consensus on a definition for this simple yet complicated issue.

During the next live edition of Monitor Mondays, Tim Brundage, MD will set the table for a robust discussion. Also on the rundown, the growing presence of private equity firms in healthcare. Given that they see healthcare as an attractive target for its investments, could their laser focus on improving profit margins potentially cross the line into Medicare fraud? Famed whistleblower attorney Mary Inman will report on False Claims Act cases that the U.S. Department of Justice has and continues to pursue against private equity for such alleged practices.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis will report on current healthcare legislation.

Mary's Bookclub: Peripheral & Cardiology Coder

Thu, 01 Sep 2022 12:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Peripheral & Cardiology Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.

Medicare Advantage: OIG Warns: Don’t Deny Payments

Mon, 29 Aug 2022 12:00:00 -0400

The warning was shot across the bow of Medicare Advantage Organizations (MAOs). The U.S. Department of Health and Human Services (HHS) Office of Inspector (OIG), in a report to the Centers for Medicare & Medicaid Services (CMS) raised concerned that MAOs could be denying prior authorizations requests in an attempt to increase profits.

CMS agreed to the report and, on Aug. 3, issued new guidance on the appropriate use of MAO clinical criteria for medical necessity reviews along with numerous revisions.

Reporting on this developing story during the next live edition of Monitor Mondays will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Substituting for Matthew Albright, will be Cate Brantley, legislative affairs analyst for Zelis. Brantley will report on current healthcare legislation.

Medicare Telehealth: The Perils of Fraud and Abuse

Mon, 22 Aug 2022 13:00:00 -0400

The public health emergency caused by Covid-19 compelled the U.S. Department of Health and Human Services to loosen the regulations to fund more telehealth services, and these "temporary" policies may be extended.

But what many may not know is that the United States has been experimenting with telehealth for 122 years, since the turn of the previous century, according to Edward M. Roche will report the lead story during the next live edition of Monitor Mondays. Roche, the Monitor Mondays investigative reporter, will review some of this history, and highlight the emerging challenges of future technologies and the continued peril of fraud and abuse.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

The Unusual Autopsy You Need to Hear

Mon, 15 Aug 2022 14:00:00 -0400

Although the “Inflation Reduction Act (H.R. 5376)” is still alive and headed to President Biden’s desk for his signature, there are provisions, deep inside the proposed legislation that will lower health care and prescriptions drug costs and could impact beneficiaries of some government-sponsored health insurance plans.

During the next live edition of Monitor Mondays, physician and attorney Dr John K. Hall will autopsy the bill, dissecting the legislation to uncover some of the relevant provisions while adding fine points and adds necessary context to this important legislation.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

False Claims Act: Whistleblower Blows the Whistle on Charity Donation

Mon, 08 Aug 2022 13:00:00 -0400

Without admitting guilt, a Florida health system entered into a $20 million settlement under the False Claims Act with the U.S. Department of Justice (DOJ) to resolve allegations that it made donations to increase Medicaid contributions. The whistleblower filed the suit alleging that the system made improper cash donations to a local charity in a scheme to increase the system’s Medicaid funding. At a time when the False Claims Act is under scrutiny, this story—to be reported by famed whistleblower attorney Mary Inman—is relevant and consequential. What lessons can be learned from this not-to-charitable scheme? Listen and learn when Inman, a partner in law office of Constantine Cannon, joins the next live edition of Monitor Mondays.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Folana Houston, assistant general counsel for Zelis, who will be substituting for Matthew Albright, will report on current healthcare legislation.

Mary's Bookclub: Essentials of Interventional Radiology Coding

Wed, 03 Aug 2022 14:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Essentials of Interventional Radiology Coding. Listen in to find out why this textbook could be a great addition to add to your essential library.

The UPICs: The Mean, the Bad and the Ugly

Mon, 01 Aug 2022 13:00:00 -0400

Like unwanted mushrooms bursting forth from your lawn, the Zone Program Integrity Contractors (ZPICs) appear to be on steroids. Their audits are aggressive disruptors in the vast auditing landscape in which providers continue to provide care and bill for the services they provide. In fact, the recent uptick in their audit activities is in the Medicaid arena. UPICs— the Centers for Medicare & Medicaid Services (CMS) contractors tasked with integrating program integrity functions for audits and investigations across both Medicare and Medicaid—are now coordinating and performing more Medicaid audits.

During the next live edition of Monitor Mondays, prominent healthcare attorney Andrew Wachler, the managing partner of Wachler and Associates, will be reporting on the ZPIC audits he is encountering while offering steps providers and suppliers can take to protect their reimbursement from recoupment.

Other segments will include these instantly recognizable broadcast segments:

Post Payment Audits: Kevin Lasser, CEO of Rev Keep, will report on the post payment audits.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Recent Supreme Court Decision Likely to Rattle Healthcare

Mon, 25 Jul 2022 13:00:00 -0400

The recent decision by the Supreme Court to invoke the major questions doctrine to nullify an agency regulation in the case of West Virginia versus the Environmental Protection Agency seems to indicate the court’s trend toward increasingly strict interpretation of statutes. The possibility that new, or even well-established, regulations may be overturned means that healthcare regulation could change drastically on extremely short time scales with no direct input from stakeholders. During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall explains the major questions doctrine and its potential impact on healthcare.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Too Big to Fail: Perception of Payer Infallibility

Mon, 18 Jul 2022 13:00:00 -0400

Are commercial payers too big to fail? Do they operate with the sense of infallibility? Case in point: UnitedHealthcare Group, which according to its earnings report, posted $4.1 billion in profits in the fourth quarter of 2021. Is the playing field level between payers and providers? For example, during the review of rejected claims does UnitedHealthcare or any private company such as this have advantages over a healthcare provider compared to what it would be if they were using the regular administrative law judge process? During the next live edition of Monitor Mondays RACmonitor investigative reporter Edward M. Roche returns to the broadcast to discuss the rights of providers in the two different appeals processes.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, Legislative Analyst for Zelis, will report on current healthcare legislation.

Mary's Bookclub: Cardiac Rhythm Management Coder

Wed, 13 Jul 2022 09:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Cardiac Rhythm Management Coder. Listen in to find out why this textbook could be a great edition to add to your essential library.

What’s the Missing Ingredient in Medicare Audits?

Mon, 11 Jul 2022 14:00:00 -0400

“Good enough for government work,” was once the saying among cynical factory workers. And yet today in healthcare, precision in Medicare statistical analysis really matters. If overpayments are found, then the extrapolation recoupment number will go up; if underpayments are found, the extrapolation will go down.

Listen and learn during the next live edition of Monitor Mondays when RACmonitor investigative attorney Edward M. Roche will report that his team routinely finds Medicare auditors handing in extrapolations that can be plus or minus 10, 15, 20, 30 percent – or even worse.

“That is somewhere between 25 and 85 percent,” wrote Roche recently in RACmonitor. “But that seems to be good enough for government work.”

Precision in Medicare auditing is a prerequisite. But, sadly—as you’ll learn from Roche—that’s not always the case.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Front and Center: Medicare Advantage Audits, Medical Necessity to Ensure Payments, and the Two-Midnight Rule

Wed, 06 Jul 2022 12:00:00 -0400

Medicare Advantage Audits, Establishing Medical Necessity to Ensure Payments, and the Two-Midnight Rule are three outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

Mary's Bookclub: Coding Essentials for Laboratories

Wed, 29 Jun 2022 10:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Coding Essentials for Laboratories. Listen in to find out why this textbook could be a great edition to add to your essential library.

Medicare Auditing Run Amok

Mon, 27 Jun 2022 13:00:00 -0400

Stranger than fiction are the reports coming from providers complaining of inconsistent and often contradictory reasons given for claim denials, leading to recoupment and the possibility of Medicare revoking privileges of participation in federal health programs – and this at a time of shrinking margins, rising inflation, budget cuts, and staff shortages. Little wonder that America’s hospitals, health systems, and physician practices are feeling the pain.

However, during the next special news edition of Monitor Mondays, you will not only hear field reports from our distinguished and highly respected panelists, but also gain the benefit of practical guidance in traversing the treacherous audit terrain.

And, as a special added feature, Monitor Mondays will conduct an exclusive roundtable on the contentious and controversial 340B drug discount program. Substituting for the program’s executive producer and program host, Chuck Buck, will be Dr. John K. Hall.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation. Brantley will be substituting for Matthew Albright.

Fighting the Rising Tide of Claim Denials: A Physician Speaks Out

Mon, 20 Jun 2022 12:00:00 -0400

Denials by payors for hospital claims continue to mount. Hospitals should take every opportunity to have a denial overturned – and an oft-neglected method is with a peer-to-peer call for a concurrent denial. A physician advisor can dedicate time and resources to accomplish it, but what do you do when the payor insists on only speaking with the attending physician?

Since this is a recurring issue with providers and auditors, Monitor Mondays has asked Dr. Chris Shearer to report on this untenable issue – and to offer advice to other providers.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Mary's Bookclub: Coding Essentials for Infusion & Injection Therapy Services

Wed, 15 Jun 2022 10:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Coding Essentials for Infusion & Injection Therapy Services. Listen in to find out why this textbook could be a great edition to add to your essential library.

Discovery of Nearly $3 Billion in Medicare and Medicaid Errors

Mon, 13 Jun 2022 12:00:00 -0400

Nearly $3 billion in expected recoveries have surfaced in the spring 2022 Semiannual Report to Congress by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). As reported by RACmonitor’s Mark Spivey, the OIG report also provides an overview of the watchdog’s activities from Oct. 1, 2021 through March 31, 2022.

During the next live edition of Monitor Mondays, providing comment and context to the report, which was published Monday, June 6, will be prominent healthcare attorney Andrew “Drew” Wachler, a longtime OIG observer and the managing partner at Wachler and Associates.

Other segments will include these instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

National Audit Roundtable: The Curse of Condition Code 44

Mon, 06 Jun 2022 14:00:00 -0400

The 2022 audit landscape is rife with pitfalls and quicksand, trapping unsuspecting hospitals, health systems, and physician practices into a financial quasi-death spiral.

And now, there’s another major disruptor: Condition Code 44, which continues to confound providers and revenue cycle professionals. Even though the Recovery Audit Contractors (RACs) have been held at bay, there are new audits targeting the proverbial low-hanging fruit, ripe for the picking. Complicating an already dismal radar screen is the return of the Inpatient-only List, bringing enormous confusion and creating the perfect setup for more audits.

Following news updates from a cadre of venerable Monitor Mondays panelists, a grouping of experts will regather around the virtual roundtable during the next edition of the live Internet broadcast, where, led by Dr. John K. Hall, attorney and physician, they will offer advice, answer your questions in real time, and forecast upcoming audits.

Preceding the roundtable, “Tales from the Audit Trail,” will be the following instantly recognizable broadcast segments:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
Roundtable Moderator: John K. Hall, MD, will facilitate the roundtable discussion focused on Condition Code 44.

Mary's Bookclub: Coding Essentials for Respiratory Therapy/ Pulmonary Function

Wed, 01 Jun 2022 13:00:00 -0400

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Coding Essentials for Respiratory Therapy/ Pulmonary Function. Listen in to find out why this textbook could be a great edition to add to your essential library.

The Continuing Saga of Condition Code 44

Mon, 23 May 2022 12:00:00 -0400

The 2 MN Rule has been with us for several years but there still is confusion about what qualifies as inpatient.

Condition Code 44 has been the corrective approach to inpatient status errors despite CMS’ warning that Condition Code 44 should not be used as a substitution for inadequate utilization management processes. Condition Code 44 can serve as a reflection that the utilization process is being monitored and claims are billed compliantly. Dr. John Zelem will review the crucial four requirements for Condition Code 44 compliance.

Other segments will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update Cate Brantley, legislative analysis for Zelis, will be substituting for Matthew Albright. Brantley will report on current healthcare legislation.

Big Pharma, Big Problems: 340B Hospitals Impacted

Mon, 16 May 2022 11:00:00 -0400

Johnson & Johnson, along with Gilead, are among the most recent pharmacy giants that have joined the list of others that are imposing restrictions on 340B drug price discounts to 340B hospitals. The latest information comes from a recent study conducted between December 2021 and March 2022 that reveals 16 other major pharmacies are flaunting the law – and their actions have doubled.

Reporting the lead story during the next live edition of Monitor Mondays will be Maureen Testoni, president and CEO of 340B Health. Testoni, a popular guest, is expected to report that consequently, the damage will continue to grow – until these pharmaceutical manufacturers are forced to restore the discounts and obey the law.

Other segments to be featured during the broadcast will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Audit Roundup: Broadcast 500

Mon, 09 May 2022 14:00:00 -0400

2010 does not seem that long ago. It’s hard to believe we’re at Monitor Mondays broadcast No. 500 since then.

But then again, let’s look at all we’ve seen change. Medicare started out with a one-midnight expectation for inpatient reimbursement. Then the Recovery Audit Contractors (RACs) moved in, showed us all the errors of our ways, and demonstrated that unrestrained denials could overwhelm the appeal system.

Then we got the two-midnight rule, which, oddly enough, seemed to make sense. It carved off a bunch of inpatient stays, but also curtailed denials. Then we saw the phase out of the inpatient-only list. But wait – the Centers for Medicare & Medicaid Services (CMS) reversed course and decided not only to keep the inpatient-only list, but to add stuff back on to it.

The one constant since 2010, via more than 500 live broadcasts,has been Monitor Mondays, bringing cutting-edge analysis of regulatory changes and providing reliable information for you to meet payor challenges. We’re looking forward to another 500 episodes. And we’re sure the payors will help us with new material.

Additional segments to be included in this landmark broadcast will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
Monday Focus: Mary Beth Pace, vice president of care management at Trinity Health, will report on outpatient status for those who have undergone surgery.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Dr. Andrew Markiewitz, substituting for Dr. Ronald Hirsch, will make his Monday Rounds.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.

The Problem List

Mon, 02 May 2022 14:00:00 -0400

Like fine wine, problem lists age very well. Too well, in fact.

Such lists can remain in place for months, even years, without being updated. And questions can lead to conflicts and errors.

Too often, problem lists simply languish, with unchanged patient encounter information. Moreover, even when a problem does appear on the problem list, it doesn’t necessarily signal that the provider addressed the issue during the patient encounter.

During the next live edition of Monitor Mondays, Dr. Andrew Markiewitz, a physician advisor and member of the RACmonitor editorial board, will delve deep into the root causes of problems in the problem list.

Other segments will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update Cate Brantley, a legislative analyst at Zelis, will report on current healthcare legislation.

Hospice in the Crosshairs: Multiple Auditors are Piling on

Mon, 25 Apr 2022 13:00:00 -0400

With the growth of Medicare hospice services comes expanded oversight on claims and care quality. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has initiated a nationwide audit of hospice claims on the heels of multiple in-depth audits of such facilities. Unified Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) have joined the hunt in recent weeks, putting all hospices on notice that vigilant compliance measures are essential. At the same time, there have been increased survey frequency and expanded sanction risk targeting these providers – and all of this will be part of the coverage of our lead story during the next Monitor Mondays broadcast.

Other segments will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Folana Houston, assistant general counsel at Zelis, will be substituting for Matthew Albright, chief legislative affairs officer for Zelis, and will report on current healthcare legislation.

Learn How to Relieve the Stress: Observation Volumes Plaguing Hospitals

Mon, 18 Apr 2022 12:00:00 -0400

How is one major hospital system reducing observation hours?

Listen to the next live edition of Monitor Mondays to find out; that’s when Mary Beth Pace will return, by popular demand, to continue her compelling discussion on how she and her team at Trinity Health are taking steps to reduce the volume of observation hours. With her laser focus on patient care, Pace will report on how the Centers for Medicare & Medicaid Services (CMS) two-midnight rule, implemented in October 2013, continues to be misinterpreted by some insurance companies to their advantage, further obfuscating patient status determination.

Pace will also discuss what should be done with payers who dictate billing status, regardless of the care provided.

Other segments will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Observation Volumes Continue to Stress Hospitals

Mon, 11 Apr 2022 15:00:00 -0400

What are your observation volumes doing to your bottom line? How much care do these patients get compared to your inpatients?

If your facility is like most facilities, the billing status does not dictate the care provided; it just dictates the reimbursement you can expect to obtain. Worse yet, it does not leverage the patient’s insurance benefits correctly.

Join us during the next live edition of Monitor Mondays as Mary Beth Pace reports on what should and could be done with the insurance companies that are dictating billing status, no matter the care provided to their card holders. Listen and learn as Pace discusses how her organization is taking on this mission to care for patients.

Other segments reported by an array of trusted subject matter experts will include the following:

SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Front and Center: Payer Contracts and 2022 Audits on Implantable Device Credits

Mon, 04 Apr 2022 16:00:00 -0400

The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center.

Great topics. Great analysis. More great educational opportunities now await you. So now get everyone on your team Front and Center.

Use code FRONTANDCENTER for 15% off your RACmonitor webcast purchases.

Uncovering Auditors’ Flawed Methodologies and Calculations

Mon, 04 Apr 2022 14:00:00 -0400

Too many times, and in too many cases, providers are being subjected to flaws in methodologies and calculations used by auditors that lead to recoupment demands and other penalties.

Aided by ambiguously written rules from the Centers for Medicare & Medicaid Services (CMS), unscrupulous auditors are often able to pounce on unsuspecting providers, wreaking havoc on revenues and human resources. The toll can be devastating. Monitoring on a daily basis providers’ concerns and questions, RACmonitor and Monitor Mondays both report on these cases, bringing to light auditors’ errors of commission and omission.

During the next live edition of Monitor Mondays, trusted subject matter experts will report on the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
The Whistleblower Report: Famed whistleblower attorney Mary Inman will report that the U.S. Department of Justice (DOJ) is joining a whistleblower lawsuit against Modernizing Medicine and a co-founder, alleging violations of the False Claims Act involving the company’s electronic health records (EHR) and kickbacks to physicians.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will return to the broadcast to report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Emerging New Audit IPO Trap: Technical Denials

Mon, 28 Mar 2022 11:00:00 -0400

The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned.

However, there are also so-called “technical denials,” in which real or alleged provider lapses in the prior authorization process arise that can be hard, or even impossible, to overcome. During the next live edition of Monitor Mondays, Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in Banning, Calif., will report on this emerging audit trap, and also discuss how to avoid or overcome these crafty insurer maneuvers.

Other segments reported by an array of trusted subject matter experts will include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.
SDoH Report: Lenel James, business lead for the Blue Cross Blue Shield Association, will report on the news that’s happening at the intersection of healthcare regulations and the social determinants of health (SDoH). Mr. James will be substituting for Tiffany Ferguson.

Auditing Gone Awry: A National News Roundup

Mon, 21 Mar 2022 13:00:00 -0400

Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fruit to be ripe for harvesting.

While the Centers for Medicare & Medicaid Services (CMS) continues to punish providers for claims submitted with errors of omission, the same disciplinary action is infrequently demonstrated publicly against payors behaving badly. It’s little wonder, in today’s highly regulated healthcare environment, that the audit landscape is fraught with peril for providers. Most notably, Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly.

For the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays.

Learn from an array of trusted subject matter experts who will report on the auditing landscape, while explaining how to protect your facility from recoupment of revenue:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
The Whistleblower Report: RACmonitor’s resident physician and attorney, Dr. John K. Hall, will report on the unusual verdict in the case of Sheldon versus Allegan Sales, LLC.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Cate Brantley, Legislative Analyst at Zelis Healthcare, will report on current healthcare legislation.
SDoH Report: Lenel James, MBA, will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

National Audit News Roundup

Mon, 14 Mar 2022 12:00:00 -0400

As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread, telehealth gained a foothold in America’s healthcare system, but that too is being subjected to audits. Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly.

It's a topic that needs to be followed closely. So for the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays.

As always, an array of trusted subject matter experts will report on the auditing landscape, and how to protect your facility from recoupment of revenue:

The Whistleblower Report: Famed whistleblower attorney Mary Inman will report on the$260 million settlement that pharmaceutical manufacturer Mallinckrodt ARD LLC has agreed to pay to resolve allegations it violated the False Claims Act by underpaying Medicaid rebates.
The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Prior Authorizations: Problems When in the Wrong Hands

Mon, 07 Mar 2022 14:00:00 -0500

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.

In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS), it states that generally, claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Uniform Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) may perform reviews based on evidence of potential fraud or gaming, and the Comprehensive Error Rate Testing (CERT) contractor may review a random sample for the purposes of estimating the Medicare improper payment rate. The RAs, however, are not listed as audit contractors allowed to audit these claims – nor should they be. So why are providers receiving audit requests for these services from their Recovery Auditors?

Reporting our lead story during the next live edition of Monitor Mondays will be Marcy Andersen, director of account management at SAI360.

Other segments to be featured during the live broadcast include the following:

The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the RAs.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

The Enigma – The Case of Richard Bagnall

Mon, 28 Feb 2022 14:00:00 -0500

It has been more than 10 years since Richard Bagnall filed suit against Kathleen Sebelius, in her role as Secretary of the U.S. Department of Health and Human Services (HHS). Since then, the case has been recaptioned several times, and bounced back and forth between the U.S. District Court for Connecticut and the U.S. Court of Appeals for the Second Circuit. But the class-action suit, now known as Barrows v. Becerra, finally now has a decision from the latter.

RACmonitor’s physician and attorney, John K. Hall, will return to the Monitor Mondays broadcast to report on whether the decision is reason for you to get excited – or just shrug.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

“Significant Enforcement” Coming Soon

Mon, 21 Feb 2022 14:00:00 -0500

In a terse, matter-of-fact announcement, the U.S. Department of Health and Human Services (HHS) is promising “significant enforcement” if providers have not complied with rules surrounding the Provider Relief Fund (PRF).

This time, HHS is focusing on whether hospitals that received PRF payments complied with the surprise billing provisions of the PRF terms and conditions. Providing an early defense warning of the imminent government audits during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates, who is expected to warn providers that these audits are likely just the beginning.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Front and Center: Medicare Advantage Audits, Spinal Procedures and 2022 IPO List

Mon, 21 Feb 2022 11:00:00 -0500

Medicare Advantage audits and spinal procedures relative to the Inpatient-Only List are two outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

Front and Center: Shared Billing, No Surprises Act & the PEPPER

Wed, 16 Feb 2022 08:00:00 -0500

These complimentary special edition podcast from RACmonitor features Chuck Buck and John Zelem, MD as they review on-demand webcasts as well as preview upcoming webcasts. Dr. Zelem offers a unique physician perspective as he explains to listeners key learning objectives from these educational webcasts.

Visit RACmonitor.com to view more informational webcasts

Drug Manufacturers Imposing Unlawful Limits on 340B Discounts

Mon, 14 Feb 2022 14:00:00 -0500

A growing number of drug manufacturers are imposing unlawful limits on 340B discounts, according to a newly released report by 340B Health. Currently, up to 13 such companies “just say no” to discounts for prescription drugs sold to safety-net hospitals and dispensed through community pharmacies.

During the next live edition of Monitor Mondays, reporting on the findings of this new report released late last month will be Maureen Testoni, president and CEO for 340B Health. Testoni is expected to report on how these major manufacturers are having a deleterious impact on 340B hospitals, while at the same time possibly harming patients.

The 340B program, established in 1992, allows these 340B providers to purchase outpatient drugs at a reduced cost and to use those savings to be invested in patient care.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Monday Focus: Mary Beth Pace, vice president of care management for Trinity Health, will report on the alarming staffing crisis among case management professionals in America’s hospitals.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Nationwide Audit Dragnet

Mon, 07 Feb 2022 12:00:00 -0500

For many third-party Medicare auditors, the only rules they follow are their own, substituting personal preference for regulatory realities – and all in the name of claim denials. Every day in nearly every American hospital, health system, or physician practice, some dedicated healthcare professional asks, “how could they do this to us?”

There is a rightful place for Medicare auditing. But too often, in too many instances, legitimate auditing takes a backseat to the arbitrary denial of claims. This week, during another live edition of Monitor Mondays, the most trusted subject-matter experts in healthcare regulation will come together to discuss the latest examples of auditing gone awry. And highlighting the role of the physician advisor, who often is asked to interpret regulations, will be Dr. Elizabeth Quinn, the National Physician Advisor Conference chair.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Medicare Auditors Caught Double-Dipping

Mon, 31 Jan 2022 14:00:00 -0500

The story first broke here on RACmonitor, when investigative reporter Edward M. Roche wrote about a case of double-dipping: the act of an auditor sampling and extrapolating against the same set of claims.

As Roche explained in his exclusive RACmonitor article, the practice is like receiving two traffic tickets for a single instance of running a red light. The practice doubles the amount of recoupment demanded. Providers pay twice.

During the next live edition of Monitor Mondays, Roche will report on this unseemly practice in general, but will also provide an update on this very same case now coming up for review by an Administrative Law Judge (ALJ).

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, who stepped down recently as the Monitor Mondays and RACmonitor subject matter expert on the social determinants of health (SDoH), will return to the broadcast for a one-time-only appearance, sitting in for Tiffany Ferguson.

Mandate Madness: On Again, Off Again

Mon, 24 Jan 2022 12:00:00 -0500

It’s an amazing spectacle being played out on network television news, talk radio, and cable news outlets: the tug-of-war between the Biden Administration and the Supreme Court. So, the question remains: when is a mandate not a mandate?

The back-and-forth over the Centers for Medicare & Medicaid Services (CMS) vaccine mandates for a wide range of healthcare providers has reached a conclusion, at least temporarily. After recent oral arguments, the Supreme Court has reinstated these CMS mandates. As such, RACmonitor’s and Monitor Mondays’ own Dr. John Hall, an attorney and physician, will have an important update and practical recommendations to help ensure that your facility is in compliance during the next edition of the weekly Internet radio broadcast.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

Reconciling Audits at the Intersection of Health and Health Equity

Mon, 17 Jan 2022 15:00:00 -0500

Public schools and facilities will be closed. Church bells will chime, while a number of flags will fly at half-mast. Because in 1983, former Republican President Ronald Reagan proclaimed that the third Monday of January would forever be observed as Martin Luther King Jr. Day.

This coming Monday, Jan. 17, Monitor Mondays will honor the slain civil rights leader with a special report recognizing efforts by various stakeholders to advance a variety of initiatives designed to improve health equity in America.

Reporting on how communities of color can benefit from regulatory efforts by the Centers for Medicare & Medicaid Services (CMS) and related federal agencies will be Lenel James, a business lead for Health Information Exchange & Innovation for the BlueCross and BlueShield Association (BCBSA). Mr. James was formerly associated with the Region V Regional Health Equity Council of Department of Health and Human Services (HHS) Office of Minority Health. In addition, he previously served on the Board of the Cosmopolitan Chamber of Commerce in Chicago, the second largest African American Chamber of Commerce in the US.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of the healthcare regulations and the SDoH.

2022: Look Out, Look Ahead

Mon, 10 Jan 2022 15:00:00 -0500

With the calamitous year of 2021 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future, on America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system for months or even years to come.

With so many major changes expected to take place in 2022, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and throughout a new year that has arrived amid a time of unprecedented uncertainty.

During the next edition of Monitor Mondays, broadcast host and RACmonitor Publisher Chuck Buck will have an all-star lineup of experts on hand to tell you what to watch out for, marking the 2022 premiere for the weekly Internet broadcast, which is celebrating 12 years of live programs.

Segments to be featured during the live broadcast include the following:

Coronavirus Update: Frontline physician Dr. John Foggle will provide a real-time update on the mysterious omicron, the extraordinarily contagious variant of the coronavirus that has gripped the nation.
Home Health and Hospice: William Dombi, president of the National Association of Home Care and Hospice, will report on the impact of COVID-19 and the public health emergency (PHE) on his Association’s members.
Medicare Advantage Report: Medicare Advantage (MA) auditors are being called, by some, nothing short of bullies. Senior vice president of clinical and regulatory affairs for Versulas Health, will report why this bulling behavior exists and how providers should deal with this ongoing issue.
IRF: One of the nation’s foremost authorities on inpatient rehabilitation facility (IRF) services, Angela Phillips will return to report on the resumption of IRF reviews by Recovery Audit Contractors (RACs).
The Special Report: Who really does own the medical record? Dr. John Zelem, founder and CEO for Streamline Solutions Consulting, will report on this controversial issue, seeking to perhaps finally resolve the decade-old mystery.
The Roche Report: RACmonitor investigative reporter Edward C. Roche will return with an exclusive story he’s uncovered while monitoring audit misbehavior nationwide from his perch in the Big Apple.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications of the recently passed surprise billing law.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will make her Monitor Mondays debut appearance, filling the shoes of Ellen Fink-Samnick, who has long reported on this timely topic with clarity and insight, but will be leaving her post as she completes her doctorate degree. Ferguson will report on the news that’s happening at the intersection of the coronavirus and the SDoH.

The Audit Roundup: Who’s at Risk and Why

Mon, 13 Dec 2021 15:00:00 -0500

The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe.

The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its features. For example, Medicare home health is moving quickly into the world of value-based purchasing. Beginning Jan. 1, 2023, all home health agencies will be subject to a national demonstration program that puts up to 5 percent of their revenue at risk by tying it to their patient care performance. Each home health agency will compete with all others to determine which providers get bonuses and which are financially penalized.

We’ll also report on the latest news and most current updates. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.

You’re an Audit Target: Special Audit Deflection Report

Mon, 06 Dec 2021 14:00:00 -0500

The auditing never stops, and the pace is quickening. New issues, new audits.

But what are the costs for hospitals seeking to avoid audits? In one of the most comprehensive reports of its kind ever offered, RACmonitor and Monitor Mondays will bring on board prescient thought leaders to define the contours of this deepening healthcare regulatory crisis. During the next edition of Monitor Mondays, our very own physician-attorney John Hall will report on the Centers for Medicare & Medicaid Services (CMS) vaccine mandate that almost happened, along withwhat this means, what you need to do, and, of course, how it might be audited.

The latest Comprehensive Error Rate Testing (CERT) report revealed more than $25 billion in improper payments. And that means that providers and suppliers will have their processes and documentation audited further. Former Recovery Audit Contractor (RAC) Medical Director Robert Glenn, MD will report on how RACs utilize similar techniques to identify audit targets.

What are the costs for hospitals trying to protect themselves from these audits? Maggie Shi, a PhD candidate at Columbia University, will share her doctorial thesis using mathematical modeling that may be beyond the comprehension of some.

We’ll also report on the latest national audit news updates from well-respected broadcast consultants, including:

RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Resisting Medicare Advantage Bullies

Mon, 29 Nov 2021 16:00:00 -0500

"It’s time to stop getting stuck thinking we have a square-peg-and-a-round-hole problem, and focus on the fact that 42 CFR codifies and makes it law that a Medicare Advantage plan, even though it has autonomy in its contract, cannot offer less benefits than Medicare. Medicare Advantage plans cannot have more restrictive guidelines than Medicare; they must at the very least adhere to the simplistic confines of traditional Medicare” – this according to Dr. Jerilyn Morrissey, who will make her debut appearance during the next live edition of the long-running Monitor Mondays broadcast.

We’ll also report on the latest news and most current updates, offering you our early-warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

A Tsunami of Medicare Audits

Mon, 22 Nov 2021 14:00:00 -0500

The signs are ominous. New final rules have been published. All the auditors are there, ready to pounce. Warnings are being sounded. It’s a tsumani of audits.

During the next live edition of Monitor Mondays, we’ll report on the latest news and most current updates, offering you our early warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

Special Report: RACmonitor investigative reporter Edward M. Roche will continue with the second installment in his three-part series that for the first time is showing how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Shooting Fish in a Barrel: More Audits Coming as CMS Releases Flurry of New Rules

Mon, 15 Nov 2021 12:00:00 -0500

Using artificial intelligence (AI), along with an uncanny ability to misinterpret rules, Medicare auditors – specifically, third-party auditors of Medicare Advantage (MA) plans – are ever-ready to pounce on healthcare providers. And too often, it’s like shooting fish in a barrel.

The recent posting of three final rules will give auditors ample opportunity to search for more inadvertent errors on Medicare claims. Last week, as reported by RACmonitor, the Centers for Medicare & Medicaid Services (CMS) posted final rules on the same day for the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS), and the Home Health Prospective Payment System (HHPPS).

More rules = more audits.

It’ll be the area of focus during the next edition of Monitor Mondays, which will also have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
Special Report: RACmonitor investigative reporter Edward M. Roche will continue with the second installment in his three-part series that for the first time is showing how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Never-Before-Revealed Secrets: How Auditors’ Bias Works Against Providers (Part I)

Mon, 08 Nov 2021 12:00:00 -0500

The next three consecutive Monitor Mondays broadcasts will constitute an explosive series, exposing for the first time how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims.

Learn about this outrageous behavior when RACmonitor investigative reporter Edward C. Roche presents the first edition of his three-part series that exposes wrongdoing that is penalizing providers and threatening their financial stability.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Open Season on Providers: Beware of the Land Mines

Mon, 01 Nov 2021 15:00:00 -0400

Operating with virtual impunity, while relying on artificial intelligence, payor auditors have locked on to providers to deny claims that trigger audits.

Acts of omission by providers are often deemed acts of commission in the eyes of auditors – and the audits often lead to recoupment. Even the slightest apparently innocuous action can trigger a cascade of negative reactions, including denials. Even knowing of misconduct is a major problem. During the next live edition of Monitor Mondays, healthcare attorney and physician John K. Hall will continue his two-part series on the consequences of seemingly inconsequential errors, and “fraud” that could very well just be the byproduct of other actions.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including::

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Audit News Roundup: Open Season on Providers

Mon, 25 Oct 2021 13:00:00 -0400

Once suspended by COVID-19, claim audits are now back on the frontburner – Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Medicare Administrative Contractor (MAC) audits, plus Targeted Probe-and-Educate (TPE) audits are the new (or renewed) normal. It’s open season on providers, which is why, in large measure, the next live edition of Monitor Mondays will feature reports on how audits now being conducted by governmental and third-party contractors are making America “Audit Nation.”
Monitor Mondays will have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Physician and attorney John H. Kall, substituting for Dr. Ronald Hirsch, will make his Monday Rounds, but also will begin a two-part series exploring the landmine liability faced by utilization management (UM) and compliance professionals. Hall is the founder of Aegis Consulting Services.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Court Report: Famed whistleblower Mary Inman, partner at the law offices of Constantine Cannon, will report on the $25 million Medicaid fraud settlement in Massachusetts, the largest ever in the Bay State.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

The Surprising Truth about the No Surprises Act

Mon, 18 Oct 2021 12:00:00 -0400

Big surprise. But not really.

The Interim Final Rule (IFR) for the federal No Surprises Act, released last month, appears to offer bad news for out-of-network providers (OON), which does not come as a surprise to heathcare attorney Thomas Force, who will return to the Monitor Mondays broadcast.

Force will explain, citing that the guidance is focused on what the bill defines as good-faith estimates for uninsured and self-pay patients, along with the Independent Dispute Resolution (IDR) process between providers, facililies, and health plans. Force contends that the IFR has left many questions unanswered, and appears to be written for the benefit of health plans and carriers. Listen during the next live edition of Monitor Mondays, when there will be new light shed on a simmering old issue: providers versus payors.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Beware: Inpatient Short Stays in the Crosshairs

Mon, 11 Oct 2021 12:00:00 -0400

The heat is on.

As reported by RACmonitor, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) auditor, has started sending out documentation requests for short-stay inpatient audits. For targeted hospitals, Livanta will select 30 inpatient admissions of Medicare beneficiaries whose length of stay (LOS) was either zero or one day within the prior three months.

So beware. And be prepared. For context on this development, Dr. John Zelem will report on the use of Occurrence Span Code 72 during the next live edition of Monitor Mondays.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Auditors Gone Wild: Rampant Fraud Reported with Medicare Advantage

Mon, 04 Oct 2021 15:00:00 -0400

Rampant auditing by Medicare Advantage (MA) plans is a constant occurrence, with notable cases being reported weekly by RACmonitor. To wit: the recent U.S. Department of Justice (DOJ) filing of a complaint in intervention in a case against Independent Health of Buffalo, New York and its coding vendor, DxID. And there’s the recent case of Sutter Health and its $90 million settlement in a MA risk adjustment fraud case.

The DOJ even intervened recently in a consolidation of six whistleblower cases against Kaiser Permanente, alleging risk adjustment fraud. Providing context and clarity on this ongoing challenge during the next edition of Monitor Mondays will be Edward C. Roche, director of scientific intelligence for Barraclough New York LLC, who asserts sarsastically, “we have rhesus monkeys auditing people like MDs, who have spent years and years learning how to make medical decisions.”

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

Crisis Standards of Care: Day Egusquiza, president of AR Systems, Inc., and a resident of Idaho, will have the latest update on the crisis-of-care rationing unfolding in Idaho, Montana, and Alaska, as the deadly Delta virus is ravaging the country. This is striking primarily the unvaccinated, who are flooding emergency departments, causing hospitals and health systems to buckle under the strain of too few beds and too few physicians.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Prepare Now Audit Frenzy Amid Hospitals Executing Crisis Standards of Care

Mon, 27 Sep 2021 13:00:00 -0400

As healthcare attorney Knicole Emanuel recently reported here on RACmonitor, in 2022 providers can expect a “frenzy” of audits – although it seems to be happening already now, as some hospitals are executing crisis standards of care while coping with an influx of COVID-19 patients (namely, unvaccinated patients who have contracted the deadly Delta variant).

The result is that many hospitals are on the brink of disaster, their resources stretched to the breaking point. Joining the next upcoming broadcast of Monitor Mondays will be John Zelem, MD, former general surgeon-turned-healthcare consultant. Dr. Zelem will report the lead story on the broadcast about the long-feared rationing of medical care now being practiced at hospitals in Idaho, Montana, and Alaska. Other hospitals are expected to soon adopt similar crisis standards of care.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

DOJ and Medicare Advantage: Famed whistleblower attorney Mary Inman, partner in the law of office of Constantine Cannon, will report on the U.S. Deptartment of Justice filing a civil complaint against a data-mining company affiliated with a Medicare Advantage (MA) plan for allegingly cheating the government out of tens of millions of dollars, thus enabling the plan to overcharge for treating patients.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.

Clinical Validation Denials: No Longer Uncommon, Definitely Unwelcomed amid Rampant Auditing

Mon, 20 Sep 2021 13:00:00 -0400

Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not present.

Reporting on these all-too-common and unwelcomed clinical validation denials will be Erica Remer, MD, a special guest during the next live edition of Monitor Mondays. Dr. Remer, a member of the ICD10monitor editorial board, is also the popular co-host of Talk Ten Tuesdays, the long-running Internet radio broadcast produced by ICD10monitor.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

National Healthcare Audit Roundup: Sutter Health Hit with $90 Million FCA Settlement

Mon, 13 Sep 2021 14:00:00 -0400

They take no breaks.

Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trusted weekly news and information Internet radio broadcast.

Featured updates from well-respected Monitor Mondays consultants include the following:

Lead Story: Famed whistleblower attorney Mary Inman, partner at Constantine Cannon, will report on the second-largest Medicare Advantage fraud settlement under the False Claims Act (FCA). California’s Sutter Health will pay the government $90 million for allegedly submitting inaccurate and unsupported medical information on tens of thousands of patients.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

National Regulatory and Audit Review: Risk of Audits for E&M Codes

Mon, 30 Aug 2021 17:00:00 -0400

2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior.

The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and does it change the potential for audit risk?

Joining the next live edition of Monitor Mondays will be senior healthcare Frank Cohen, who will report the results of his study of more than 30,000 audits of office visit codes.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

UnitedHealth Under Fire

Mon, 23 Aug 2021 13:00:00 -0400

In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims.

The decision is likely to have serious ramifications, to the tune of tens of billions of dollars. It’s been estimated that such MA overpayments in 2016 soared to more than $16 billion.

The bad news is that private payers like UnitedHealth must return overpayments. The good news is a possible payday for providers who surrendered billions of dollars to private payers.

Reporting our lead story during the next edition of Monitor Mondays will be prominent healthcare attorney Andrew Wachler, managing partner in the law firm of Wachler and Associates.

To learn more about the details of this recent ruling and its implications for providers (and payers), listen to the next live edition of the weekly Internet radio broadcast, coming your way on Monday, Aug. 23 at 10 a.m. EST.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Observation versus Inpatient Divide Heralds Surge in Denials and Audits

Mon, 16 Aug 2021 14:00:00 -0400

The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits.

Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the low-hanging fruit created when administrators, physician advisors, and case managers aren’t on the same page, putting hospitals at even greater risk for more denials, lower reimbursement, and longer lengths of stay. It’s a conundrum documented in a nationwide survey undertaken by Sound Physicians and reported on by Chris Shearer MD, MPH, chief medical officer in the organization’s Physician Advisor Services section.

To learn more about the extent of recent auditing activities, listen to the next live edition of Monitor Mondays, coming your way on Monday, Aug. 16 at 10 a.m. EST.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Spike in Audit Activity Sets Off Alarm Bells: A Regulatory News Update

Mon, 09 Aug 2021 13:00:00 -0400

Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries.

Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn the extent of recent auditing activities, listen to the next live edition of Monitor Mondays, coming your way on Monday, Aug. 9 at 10 a.m. EST.

You’ll also learn about the extraordinary move by the U.S. Department of Justice (DOJ) to intervene in whistleblower lawsuits brought by Constantine Cannon against Kaiser Permanente, one of the nation’s largest managed care organizations (MCOs), which has been accused of knowingly submitting false claims for risk-adjusted payments to the Centers for Medicare & Medicaid Services (CMS). Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will return to the broadcast next Monday to report on this developing story.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Audit and Regulatory News Roundup: A New Surge in Post-Pandemic Audits

Mon, 02 Aug 2021 16:00:00 -0400

Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight.

Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation.

Adding insult to injury is a new ruling handed down by the 5th Circuit Court allowing the U.S. Department of Justice (DOJ) to dismiss a whistleblower’s False Claims Act (FCA) suit. What does this decision mean for whistleblower cases? And, more generally, what does it mean for whistleblower outsiders who do their own independent analyses and investigations to launch an FCA case? Famed whistleblower Mary Inman, partner in the London office of Constantine Cannon, will return to the Monitor Mondays broadcast this week with an exclusive report on this developing story.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Law and Order: Post-Pandemic Audits

Mon, 26 Jul 2021 12:00:00 -0400

The COVID-19 pandemic might have subsided somewhat, but in the eyes of the Centers for Medicare & Medicaid Services (CMS), it is anything but over, as the agency continues to treat providers as if it were still surging.

In order of priorities, CMS is starting to push Targeted Probe-and-Educate (TPE) audits, according to healthcare attorney Andrew Wachler. He reports that his firm is starting to see activity of this nature, noting that before the pandemic, there were more than 13,500 such audits, adding that the consequences can be severe if not handled properly.

Next on his agenda during the next live edition of Monitor Mondays, Wachler will discuss audits and a False Claims Act (FCA) case relating to the Provider Relief Fund. And looking ahead, Wachler will report on what he expects to see with potential audits, actions he expects to see in telehealth, and the various areas of telehealth that feature the greatest exposure.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Rampant RACs: Auditor Industry Profiting at Providers’ Expense

Mon, 19 Jul 2021 16:00:00 -0400

SPECIAL GUEST
Edward Roche, JD, PhD
Director, Scientific Intelligence, Barraclough NY LLC

ALSO FEATURING
Matthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP;
David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQ

RACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant abuse directed at healthcare providers by overzealous (and, in some cases, incompetent) auditors.

Relying on scant evidence of actual fraud, the auditors, working in what Roche describes as a giant industry, deny claims while ignoring more the egregious cases of premeditated fraud and abuse. During the next live edition of Monitor Mondays, Roche will be calling for major reform of these auditing practices, claiming in an exclusive segment that the sprawling industry of coding experts, consultants, lawyers, and statisticians seldom catch the real perpetrators of fraud and abuse.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

Battle Lines Have Been Drawn: Saving 340B Discounts

Tue, 13 Jul 2021 11:00:00 -0400

Six major U.S. drug manufacturers are refusing to provide 340B discount pricing for outpatient drugs sold to safety-net hospitals, community health centers, and public health clinics when those drugs are dispensed in community pharmacies.

Will it take an act of Congress to intervene in this ongoing battle to restore 340B discounts and refund overcharges? Maureen Testoni, J.D., President and CEO of 340B Health, will bring us up to speed on this rapidly developing situation during the next live edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Billing Code 44: Physician advisor Andrew Markiewitz, MD will return to the broadcast to report on why getting Medicare inpatients into the correct status creates an administrative wrinkle: the dreaded billing Code 44.

A Cautionary Tale: Submitting a Higher-Weighted DRG

Mon, 28 Jun 2021 13:00:00 -0400

If your facility is considering submitting an amended claim request for a higher-weighted diagnosis-related group (HWDRG), be aware: the Centers for Medicare & Medicaid Services (CMS) has the authority to have your amended claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

And that alone could open up Pandora’s Box. Reporting our lead story during the next live edition of Monitor Mondays will be Susan Gatehouse, founder and CEO for Axea Solutions. Gatehouse, also a popular panelist on Talk Ten Tuesdays, will report on the possible consequences of such an action while providing guidance on how to ensure all your ducks are in a row.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

Avoid this Top 100 Hospital List

Mon, 21 Jun 2021 14:00:00 -0400

There are lists upon lists of hospital rankings. But there’s one list you’ll certaintly want your hospital to avoid.
A report from Johns Hopkins University has revealed that many of America’s top 100 hospitals are using predatory tactics to pursue lawsuits against patients. Highlighting this list are government hospitals as well as nonprofit health systems called out for hounding patients to collect debt for services provided.

The Patient Protection and Affordable Care Act (PPACA), which survived a third challenge in the U.S. Supreme Court recently, specifically bars hospitals from engaging in this type of behavior.

“(This) may be a good time to relook at your financial assistance policy and ensure you are following appropriate guidelines according to the PPACA, particularly if your institution is a nonprofit,” says Tiffany Ferguson, who will report on the story during the next live edition of Monitor Mondays. “Remember that financial assistance is applied to all emergency and medically necessary care in the hospital facility.”

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

UnitedHealthcare Poised to Deny ED Claims

Mon, 14 Jun 2021 14:00:00 -0400

UnitedHealthcare is the latest insurer to join the growing lineup of payors that want to second-guess patients and deny payment for emergency department (ED) services after they’ve been rendered.

As reported here on Monitor Mondays last week, UnitedHealthcare plans to extend no coverage or limited coverage to ED claims, retroactively – including any claims the giant insurer deems non-emergent. Our own Dr. John K. Hall will report on this recent development during the next edition of the Monitor Mondays broadcast, offering tips on how to prepare for the consequences of these denials.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Court Report: Famed whistleblower attorney Mary Inman, partner at the London office of Constantine Cannon, will return to the broadcast to report on the latest wrinkle in the whistleblower lawsuit launched by Integra Med Analytics. The Department of Justice (DOJ) has intervened in one Integra case against 11 nursing homes.

Quality Audits and Malpractice Suits: How 2021 E&M Guidelines Raise Medical/Legal Issues

Mon, 07 Jun 2021 16:00:00 -0400

Are your physicians providing detailed documentation as they adhere the 2021 Evaluation and Management (E&M) Guidelines? Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement, is concerned that they might not be – which, he believes, squarely puts them in an uphill battle, defending themselves from quality audits and potential malpractice suits. And Cohen has the numbers to back up his concerns, which he will share during the next live edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

What Happened to the ALJ Logjam?

Mon, 24 May 2021 14:00:00 -0400

There was a time when the word “logjam” seemed to be synonymous with the Administrative Law Judge (ALJ) hearings conducted under the purview of the Office of Medicare Hearings and Appeals (OMHA).

Today, by all accounts, hearings are being scheduled almost back-to-back, and attorneys are scrambling to represent their clients during unprecendented times. Preparing for a multi-million-dollar hearing on Tuesday, May 25 is Andrew Wachler, managing partner at Wachler and Associates – and the cases he’s working have dates of service dating back to 2009 and 2010. With a long-established presence at the ALJ level of appeal, Wachler will brief Monitor Mondays listeners on the new reality during the next edition of the weekly Internet radio broadcast.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

Resources: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000585.asp

Audit Nation: The Growing Impact of Claims Auditing on Healthcare

Mon, 17 May 2021 15:00:00 -0400

“Incoming!” are the typical dreaded shouts heard from soliders hunkered down in bunkers when shelling begins.

Today, across America, you can hear the same cries when it comes to claims auditing. Audits are incoming. Third-party auditors, governmental auditors, even auditors from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) looking at COVID-related claims are incoming – and the onslaught is occurring in rural hospitals as well as big city health systems and teaching facilities alike.

Does this portend a future of escalating audits? During the next live edition of Monitor Mondays, an all-star lineup of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast.

The live broadcast includes the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
The Court Report: Famed whistleblower Mary Inman, a partner in the London office of Constantine Cannon, will report on three notable whistleblower suits, all involving well-known healthcare brands.
The Analysis: E&M 2021 Guidelines: Senior healthcare analyst Frank Cohen, director of business intelligence for DoctorsManagement, will report on his latest analysis of evaluation and management (E&M) 2021 guidelines for office visits; noteworthy will be his analysis of medical necessity audits.
Utilization Management versus Utilization Review: Dr. John Zelem, founder of Streamline Consulting Services, will return to the broadcast to explain why utilization management and utilization review are not to be used interchangeably, yet they are, with increased frequency.
Jab City, USA: Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Warren Alpert Medical School of Brown University, and an authority on the coronavirus will return to the broadcast to report on vaccine rates in the U.S. – as most experts warn that herd immunity is not likely to be achieved in the near future.
Law and Order: Monitor Mondays’ own physician and attorney, Dr. John K. Hall, will report on the 11th Circuit Court of Appeals decision in the American College of Emergency Medicine versus Blue Cross and Blue Shield of Georgia. Understanding and applying the court's decision will help you and your team when faced with denials for services provided in your emergency department.

Audit and Regulatory News Roundup: OIG Audits Latest Development

Mon, 10 May 2021 14:00:00 -0400

Several hospitals have now received audit notices from the HHS Office of Inspector General (OIG) for COVID-related claims. The OIG has begun auditing hospitals to “determine whether Medicare paid hospitals for these inpatient claims in accordance with federal requirements.” Make no mistake, the OIG is auditing provider billing, not payment. The OIG is not auditing Medicare Administrative Contractor (MAC) performance, according to physician and attorney John K, Hall, MD. Dr. Hall who will return to Monitor Mondays to report this developing story.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

The Perpetual Appeals Machine: The ALJs and Medicare Appeals Council

Mon, 03 May 2021 13:00:00 -0400

What percentage of administrative law judge (ALJ) decisions end up at the Medicare Appeals Council? What percentage of those decisions are reversed?

These are important questions asked by a reader in response to a recent article written for RACmonitor by Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement. Cohen, who has extensive experience as a subject matter expert in ALJ hearings, will look under the hood of the perpetual appeals machine, while sharing insight into the appeal process – describing how it is broken and why.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.

Knock, Knock. Who’s There? OIG Warns of COVID-19 Scammers

Mon, 26 Apr 2021 15:00:00 -0400

They’re using text messages. They’re offering vaccination cards, and even COVID-19 testing. They’re scammers.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is currently warning that providers that charge impermissible fees must refund them, and ensure that individuals are not charged any sum at all, for the COVID-19 vaccine – along with warning of fraudulent telemarketing calls and even door-to-door visits. Of particular concern are scammers pretending to be COVID-19 contact tracers.

“Legitimate contact tracers will never ask for your Medicare number or financial information, or attempt to set up a COVID-19 test for you and collect payment information for the test,” the OIG notes on its website.

Just how prevalent are these scams? Reporting our lead story during the next live edition of Monitor Mondays will be RACmonitor investigative reporter Ed Roche, who was among the very first to report on contact tracers during the early stages of the pandemic, here on Monitor Mondays and RACmonitor.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Monday Rounds: Attorney and physician John K. Hall, MD, founder of the Aegis Firm, will be pinch-hitting for Ronald Hirsch, MD, who regularly makes his rounds on Monitor Mondays.

Blame the RACs for the ALJ Backlog

Mon, 19 Apr 2021 13:00:00 -0400

With little in the way of reporting on the backlog of appeals at the Administrative Law Judge (ALJ) level, you could conclude that such hearings are on hiatus.

But that’s not the case, according to senior healthcare consultant Frank Cohen, who will be reporting the lead story during the next live edition of Monitor Mondays. Cohen, director of business intelligence at DoctorsManagement, is expected to report that while he had testified at four ALJ hearings in all of 2019-2020, he has already testified at four so far this year, with four more between now and June – all pertaining to cases from 2014-2015. Ask Cohen why the Recovery Audit Contractors (RACs) are to blame for the backlog – his answer will be one you may not expect.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Monday Rounds: Attorney and physician John K. Hall, MD, founder of the Aegis Firm, will be pinch-hitting for Ronald Hirsch, MD, who regularly makes his rounds on Monitor Mondays.

Aging Bridges, Road and Patients: Infrastructure Pitch Comes with a Human Touch

Mon, 12 Apr 2021 18:00:00 -0400

President Joe Biden’s roughly $2 trillion infrastructure proposal, called the “American Job Plan,” includes approximately $400 billion to expand access to home care and community-based services, including access to long-term care provided under Medicaid.

Reporting on the impact of this possible new fusion of funding during the next edition of Monitor Mondays will be William Dombi, president of the National Association for Home Care and Hospice. No stranger to broadast listeners, Dombi’s appearance comes at a time when the nation continues to grapple with the coronavirus pandemic, which in turn has illuminated the need for keeping those with the greatest risk potential for the deadly virus in a home-care environment.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Stanley Nachimson, former Centers for Medicare & Medicaid Services (CMS) career professional-turned-well-known healthcare IT authority, will report on two proposal rules posted by CMS.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Facing a Fourth Wave: COVID-19 Update

Mon, 05 Apr 2021 15:00:00 -0400

The initiative to vaccinate enough Americans to achieve herd immunity against the deadly coronavirus appears to be stalling – this in the face of increases in infection rates.

According to data from the Centers for Disease Control and Prevention (CDC), the country has experienced an average of 65,000 new cases in the last seven days. Reporting our lead story during the next edition of Monitor Mondays will be John Foggle, MD, who returns to the broadcast following his stint as a frontline physician caring for COVID-19 patients at Rhode Island’s alternative site field hospital as a member of Brown University’s emergency medicine department. Dr. Foggle has a distinguished career in medicine, particularly as it relates to his being a consultant with the World Health Organization (WHO) in Fiji and Tonga at the global outbreak of the virus in late February and early March 2020, designing guidances and conducting healthcare worker training in preparation for COVID-19.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
- Resource: https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/cardiology/QRG-Cardiology-Notification-Program-for-Commercial-Plans.pdf

Appealing Ridiculous DRG Denials: Rearranging Deck Chairs on the Titanic?

Mon, 29 Mar 2021 17:00:00 -0400

“Ridiculous denials are frustrating. Vent, and then respond,” Dr. Andrew Markiewitz advises. “But ask: are you arguing over the Titanic’s deck chairs?”

“Insurers may correctly identify unsubstantiated diagnoses,” Markiewitz added – and, if their findings are legitimate, return the money. If the DRG or reimbursement doesn’t materially change, after all, where’s the value?

Fighting the fight worth fighting will be the topic of the next edition of Monitor Mondays, when Markiewitz, a physician advisor at the Cincinnati-based TriHealth, Inc., will share his experiences in appealing DRG denials.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

National Regulatory and Audit News Update

Mon, 22 Mar 2021 13:00:00 -0400

Healthcare data breaches and the possibility of sanctions from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) are a rightfully terrifying possibility for healthcare administrators.

But one hospital, MD Anderson Cancer Center, recently fought back and won. Reporting on the outcome of the decision handed down by the 5th Circuit Court of Appeals during the next live broadcast of Monitor Mondays will be Dr. John K. Hall, a physician and attorney. Hall, founder of the Aegis Group, will provide an analysis of the case, while offering valuable lessons that can be learned from it.

Other segments to be featured during the live broadcast include the following:

Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

Novel Legal Approaches to Defend Audits: Listen and Learn

Mon, 15 Mar 2021 18:00:00 -0400

Now that the auditing reset button has been pressed, you and other providers can expect a torrent of audits and recoupments. In this new aggressive auditing environment, propelled by commercial as well as governmental auditors, providers must continually update their approach in response.

Against this chaotic background, there’s a new legal approach to audit defense advocated by Wachler & Associates. During the next live edition of Monitor Mondays, prominent healthcare attorney Andrew Wachler, managing partner at Wachler and Associates, will report on the latest legal theories, based on recent case law, to respond to technical and other audit denials.

Other segments to be featured during the live broadcast include the following:

Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

Bed Hijacking: Outpatients Assigned to Inpatient Beds

Mon, 08 Mar 2021 13:00:00 -0500

“Are your CFOs agitated by the increase of outpatients in inpatient beds because of the removal of total knee arthroplasty (TKA), total hip arthroplasty (THA), and hundreds of other procedures from Medicare’s Inpatient-Only List (IPO) list?” asked Julie Collins recently on the RAC Relief listserv. “If the surgeon’s office is securing the prior authorization, how are they doing with securing the proper classification (inpatient/outpatient)? Are they using a dartboard to determine which classification they request?”

During the next live edition of Monitor Mondays, Collins, manager of utilization management at TriHealth in Cincinnati, Ohio, will report on how her healthcare system is addressing this crucial issue.

Other segments to be featured during the live broadcast include the following:

Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

Regulatory News Roundup: Major Changes Underway by the New Administration

Mon, 01 Mar 2021 15:00:00 -0500

Changes to the nation’s Medicaid program, which reportedly covers some 70 million people, are expected soon. According to news reports, among the looming changes is the elimination of the work requirement for Medicaid recipients.

This will mark the featured topic during the next live edition of Monitor Mondays, when healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report on this change and others that will affect providers.

Other segments to be featured during the live broadcast include the following:

Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

New Revelations Emerge Illuminating Misinterpretations of Condition Code 44

Mon, 22 Feb 2021 16:00:00 -0500

After all this time, you could still be doing it wrong when it comes to Condition Code 44.
If your hospital has been following the Medicare Condition Code 44 process associated with 42 CFR 482.30 because policy issued by the Medicare Advantage or commercial plans with which you’re contracted dictates its use, this may be the case, according to Dr. Juliet Ugarte Hopkins, the special guest during the next live edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.

It’s All About Change: MCG and InterQual

Mon, 15 Feb 2021 17:00:00 -0500

With the purchase by UnitedHealthcare (UNC) of Change Healthcare, providers are contemplating notable differences between two sets of quidelines. Change Healthcare owns InterQual criteria, while UHC has traditionally used MCG criteria.

Becoming familiar with the variances in terms of observation timeframes, screening methodologies, severity of illness thresholds, and intensity of service thresholds for levels of care will be the topic reported on by Kelvin Valera, MD, a healthcare consultant and physician advisor, during the next edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report that the pharmaceutical company Roche and Medicare Advantage insurer Humana have agreed to pay $12.5 million to the U.S. government to resolve allegations that the companies violated the anti-kickback statute – marking the first False Claims Act (FCA) settlement resulting from a pharmaceutical company’s alleged payment of kickbacks to a Medicare Advantage Organization.

Exclusive: Medical Device Credits in OIG Crosshairs

Mon, 08 Feb 2021 14:00:00 -0500

To ensure compliance in conveying device credits and to identify providers who do not, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has a specific Annual Work Plan item to address the matter.

Either through targeted device credit audits or enveloped in broader general billing compliance regulations for hospitals and ambulatory surgical centers (ASCs), the OIG is clearly seeking to ferret out “noncompliers.” Adding fuel to the fire, the OIG also has a related Work Plan item based on device credits already reported, but done improperly: outpatient outlier payments for claims.

Reporting our lead story during the next edition of Monitor Mondays will be Michael G. Calahan, PA, MBA, AHIMA-approved ICD-10-CM/PCS trainer and vice president of hospital and physician compliance with HealthCare Consulting Solutions (HCS). Calahan will also reveal five critical mistakes providers often make in trying to comply with these stringent rules.

Other segments to be featured during the next live broadcast include the following:

Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

Billions in Overpayments Levied Against Providers by CMS; Uncovering Flaws in Methodology

Mon, 01 Feb 2021 13:00:00 -0500

Billions of dollars in overpayments are levied annually against healthcare providers by the Centers for Medicare & Medicaid Services (CMS), based on the use of extrapolation audits. And while thousands of extrapolation audits are completed each year, the targeted provider or organization most likely will appeal the use of extrapolation.
In nearly all cases, the appeal is focused on one or more flaws in the methodology used to create the sample and calculate the extrapolated overpayment estimate. But how do you uncover the flaws?

Reporting our lead story during the next edition of Monitor Mondays, with answers to that question and others, will be Frank Cohen, senior healthcare analyst and director of business intelligence at DoctorsManagment.

Other segments to be featured during the next live broadcast include the following:

Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

COVID-19 News Update – The Mask Mandate

Mon, 25 Jan 2021 13:00:00 -0500

Even as the nation continues to struggle with the coronavirus pandemic, President Joe Biden, who took office Thursday as the 46th President, signed executive orders mandating that masks be worn on federal property and for interstate travel on trains, transit systems, and airlines – this being part of the President’s agenda for the first 100 days in office. Meanwhile, shortages of the COVID-19 vaccine are being reported throughout the country, most notably in the Big Apple, where New York City Mayor Bill de Blasio reportedly said the city would exhaust its vaccine supply this week.

Reporting our lead story during the next edition of Monitor Mondays will be John Foggle, MD, a frontline physician caring for COVID-19 patients at Rhode Island’s alternative site field hospital as a member of Brown University’s emergency medicine department.

Other segments to be featured during the live broadcast include the following:

Cyber Watch: Special Series: RACmonitor investigative reporter Edward Roche will begin a new series on Monitor Mondays, focusing on cyber security issues imperiling the U.S. In his first report, Roche will describe how New York City is a city in crisis when it comes to how it is confronting serious issues related to its massive vaccination program – it’s not working.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

Increases in Physician Payments Also Means Greater Recoupment

Mon, 18 Jan 2021 14:00:00 -0500

Most physicians are expected to see in an increase in payments from Medicare, thanks to the latest COVID-19 relief bill. But with good news always comes some caution.

First of all, the more that is paid, the more can be recouped during an audit. And with respect to provider compensation models that rely on relative value units (RVUs), it is possible that the increase in work RVUs may exceed the increase in the total RVUs – meaning that a provider may make more than what is proportional to overall practice revenue. This could have implications with respect to fair-market value, and should be watched very closely.

Reporting our lead story on this timely matter during the next live edition of Monitor Mondays will be Frank Cohen, senior healthcare analyst and director of business intelligence at DoctorsManagment.

Other segments to be featured during the live broadcast include the following:

Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

2021: Look Out, Look Ahead

Mon, 11 Jan 2021 15:00:00 -0500

With the calamitous year of 2020 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future of America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system.

With so many major changes expected to take place in 2021, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and throughout a new year that has arrived amid a time of unprecendented uncertainty.

During the next edition of Monitor Mondays, host and RACmonitor Publisher Chuck Buck will have an all-star lineup of experts on hand to tell you what to watch out for, marking the 2021 premiere for the weekly Internet broadcast, which is celebrating 11 years of live programs.

Segments to be featured during the live broadcast include the following:

340B Health: The president and CEO for 340B Health, Maureen Testoni, is expect to report on a recent advisory opinion from the U.S. Department of Health and Human Services (HHS) General Counsel, saying that drug companies denying 340B discounts to hospitals using community-based pharmacies are wrong and should stop.
COVID-19: Frontline physician John Foggle will provide a real-time update on the raging spread of the coronavirus, at a time when public health experts are predicting that the U.S. death toll could eclipse 450,000 by February.
Home Health and Hospice: William Dombi, president of the National Association of Home Care and Hospice, will report on the impact of COVID-19 and the public health emergency (PHE) on his association’s members.
IRF: One of the nation’s foremost authorities on inpatient rehabilitation facility (IRF) services, Angela Phillips will return to report on the resumption of reviews by Recovery Audit Contractors (RACs) on IRFs.
The Special Report: Should medical record auditors be certified? RACmonitor investigative reporter Ed Roche will report on why he believes there is a need.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications of the recently passed surprise billing law.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Regulatory News Roundup: A Special 60-Minute Open Door Forum

Mon, 07 Dec 2020 15:00:00 -0500

Amid the chaos created by the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) released two major final rules this week: the 2021 Physician Fee Schedule and the Outpatient Prospective Payment System (OPPS), with the latter having been widely anticipated. Both final rules portend significant new regulatory changes for providers, patients, and payors. Given the gravity of these new changes, the next upcoming Monitor Mondays broadcast will encompass a special live open door forum to answer questions from listeners.

Segments to be featured during the live broadcast include the following:

Court Report: Famed whistleblower attorney Mary Inman, partner in the London law office of Constantine Cannon, will return to the broadcast to report on three major whistleblower cases.
COVID-19: Frontline physician John Foggle will provide a real-time update on the raging spread of the coronavirus — at a time when Centers for Disease Control and Prevention (CDC) Director Robert Redfield is predicting that the U.S. death toll from COVID-19 could eclipse 450,000 by February.
Monday Focus: Utilization Review: Dr. John Zelem, founder of Streamline Solutions Consulting, Inc., will report on the role of utilization review amid the pandemic.
Rural Health Report: The nation’s rural communities are reported to be ravaged by COVID-19. Leslie Marsh, the CEO for Lexingtion Regional Health Center, will report on how her facility is being impacted by the pandemic.
The Special Report: Andrew Dombro, MD will report on the impact of COVID-19 on providers and patients engaged in chronic care management.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

$6.38 Million Medicare Advantage Whistleblower Settlement

Mon, 30 Nov 2020 13:00:00 -0500

A whistleblower recently exposed an alleged risk-adjustment scheme that was apparently designed to artificially inflate reimbursement provided under Medicare Part C, aka Medicare Advantage (MA).

The accompanying lawsuit alleged that GHC hired an outside vendor to review and “improve” its risk adjustment scores. According to the whistleblower, GHC submitted t

Reporting our lead story on this matter during the next live edition of Monitor Mondays will be Max Voldman, JD, an associate of Constantine Cannon.

Other segments to be featured during the live broadcast include the following:

Special Report: Bereavement: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will don her case management hat to report on how hospital personnel are dealing with the death of patients in the wake of COVID-19, which has claimed the lives of more than 259,000 here in the U.S. Ellen will also conduct the Monitor Mondays Listeners Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

COVID-19: Coronavirus and Compliance A Special 60-Minute Open Door Forum

Mon, 23 Nov 2020 16:00:00 -0500

The next upcoming Monitor Mondays broadcast will encompass a special live open-door forum, coming at the intersection of compliance and the coronavirus – a jarring combination, in light of the fact that the continuing viral pandemic has claimed the lives of more than 250,000 and infected more than 11 million in the U.S.

It is here, at this critical point, that providers are reconciling a patchwork of regulatory waviers while addressing the urgent need of helping patients in their struggle to survive. Adding a layer of complexity is the spectre of audits and the ever-watchful eye of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

In recognition of the confusion, the next edition of Monitor Mondays will also be extended to 60 minutes, allowing for questions and answers.

Other segments to be featured during the live broadcast include the following:

OIG Report: RACmonitor investigative reporter Edward Roche will report on the latest move by the OIG that faults Medicare contractors for being inconsistent in their review of extrapolated overpayments amid the appeal process.
COVID-19: Frontline physician John Foggle will return to the broadcast to provide a real-time update on the raging spread of the coronavirus – at a time of widespread holiday travel for Thanksgiving.
Special Report: Andrew Dombro, MD will report on the impact of COVID-19 on providers and patients engaged in chronic care management.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Attorney Ashley Thomson, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Triaging Denials: Emphasize Preparation, Don’t Panic

Mon, 16 Nov 2020 14:00:00 -0500

There has recently been, as some might suggest, the luxury of taking a brief hiatus from medical record audits.

But that was then, and this is now.

Because now is the time to prepare, assess timeframes and provider requirements, and ensure that a proper compliance plan is in place. Certainly, audits are a growing source of concern, but there is no need for panic when adequately prepared, as you’ll learn from Susan Gatehouse, founder and CEO for Axea Solutions, who will be the special guest during the next live edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Avoiding a Major Healthcare Crisis: The Need to Bring Back Post-Acute Waivers

Mon, 09 Nov 2020 14:00:00 -0500

The coronavirus winter surge is quickly approaching, and at a time when the United States is experiencing record numbers of daily positive COVID-19 tests, with corresponding increases in hospitalizations expected to follow. What the country needs now is for payers – both governmental and commercial – to reinstitute post-acute authorization waivers, since such waivers have largely expired. Currently, UnitedHealthcare, Aetna, and Anthem have no post-acute authorization waivers in place for any patients, including COVID-19 patients.

Without these waivers, hospitals must again go through the authorization process for post-acute stays. Reporting our lead story during the next edition of Monitor Mondays will be Dr. Edward Hu, system executive director of physician advisor services for UNC Health in North Carolina.

Other segments to be featured during the live broadcast include the following:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen also conducts the Monitor Mondays Listeners Survey.

Civil Monetary Penalties for Paying Ransomware Demands

Mon, 02 Nov 2020 13:00:00 -0500

The United States Department of the Treasury’s Office of Foreign Assets Control (OFAC) recently issued an advisory on potential sanction risks for facilitating ransomware payments. It warned that entities, including hospitals, paying off ransomware demands might be subject to civil monetary penalties under the International Emergency Economic Powers Act (IEEPA).

This action places hospitals in danger of being guilty of such violations, even when they are the victim of a crime. Reporting our lead story during this edition of Monitor Mondays is RACmonitor investigative reporter Ed Roche, who has been reporting on ransomware for RACmonitor since 2017.

Other segments featured during the podcast include:

Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Beware of Audit Hot Spots Highlighted by the CARES Act

Mon, 26 Oct 2020 14:00:00 -0400

Providers that received payments from the federal Provider Relief Fund will be required to file reports demonstrating their compliance with the terms and conditions of those payments.
Reporting on this, our lead story during the next live edition of Monitor Mondays, will be healthcare attorney Andrew Wachler, managing partner of Wachler & Associates. Mr. Wachler will report on anticipated “hot spots” in the auditing of the use of these payments, including healthcare-related costs and lost revenue attributable to the coronavirus and expenses that have been reimbursed from other sources.

Other segments to be featured during the live broadcast include the following:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Audit Report: Sean M. Weiss of DoctorsManagement will return to the broadcast with an update on comparative billing reports (CBRs), reporting that providers need to change their billing patterns to avoid financial losses.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Stopping the Bleeding: More Cuts Proposed for 340B

Mon, 19 Oct 2020 15:00:00 -0400

More payment cuts are being proposed by the Centers for Medicare & Medicaid Services (CMS) for next year, a move sure to impact the many hospitals participating in the 340B drug discount program, as described in the 2021 Medicare Outpatient Prospective Payment System (OPPS) Proposed Rule.

Such proposed cuts are expected to reduce Medicare Part B drug payments to levels lower than in 2018, when the last round of cuts were made. Reporting our lead story during the next edition of Monitor Mondays will be Maureen Testoni, CEO for 340B Health. Also participating in the broadcast will be ICD10monitor national correspondent Timothy Powell, CPA, who will report on the expected financial impact of those proposed cuts to critical access hospitals (CAHs).

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Special Report: Even though length of stay (LOS) continues to generate buzz, there might be an alternative to the long-heralded metric. John Zelem, board-certified-surgeon-turned healthcare consultant, will report on another set of criteria that could be gaining traction.
Audit Report: Sean M. Weiss of DoctorsManagement will return to the broadcast with an update on the increase in auditing activity by federal contractors.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
IFR Report: Angela Phillips, PT, president and chief executive officer for Image and Associates, considered by many to be one of the nation’s foremost authorities on inpatient rehabilitation facility compliance, returns to the broadcast to report on how the issue of “medical necessity” for IFR stays is prompting concerns about audits and denials.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications that have the potential to put providers at risk.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Has Focus on Length of Stay Run its Course?

Mon, 12 Oct 2020 13:00:00 -0400

The venerable topic of length of stay (LOS) has recently been generating buzz among healthcare professionals – so much so that we asked Stefani Daniels, founder and managing partner of Phoenix Management, to return to the weekly Monitor Mondays broadcast with an update, noting that the use of LOS has apparently declined.

But is it still a valuable metric? And how might LOS be used today? This question becomes even more relevant as hospitals work to improve efficiencies, reduce costs, and perhaps, decrease LOS.

Other segments featured during this episode include:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
Special Report: The Centers for Medicare & Medicaid Services (CMS) Price Transparency Final Rule becomes effective Jan. 1, 2021. Frederick Stodolak, president and CEO of Panacea, will return to the broadcast to report on how providers should prepare now for this initiative by CMS mandating that hospitals disclose their prices for items and services.
Audit Report: Former payer auditor, Robin Sewell, founder of Cleopatra “Queen of Denial,” Revenue Cycle Denial Management and Prevention, will make her Monitor Monday debut reporting on the latest regulatory audits.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications that have the potential to put providers at risk.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Telehealth Fraud Bust: Fed Takedown Nets $6 Billion, 345 Defendants

Mon, 05 Oct 2020 14:00:00 -0400

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently closed in on more than 345 defendants charged with participating in scams involving more than $6 billion in alleged losses to federal healthcare programs.

The takedown occurred in September, according to the OIG. Of that amount, approximately $4.5 billion was associated with telemedicine schemes. The action by the feds puts a spotlight on the growing use of telehealth as a consequence of the ongoing coronavirus pandemic.

Reporting our lead story during this edition of Monitor Mondays is John K. Hall, an attorney and physician.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen also conducts the Monitor Mondays Listeners Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications that have the potential to put providers at risk.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

CMS Orders Medicare Advantage Organizations to Cease “Pseudo Denials” to Non-contracted Providers

Mon, 28 Sep 2020 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) has moved to stop Medicare Advantage Organization (MAO)-hired subcontractors from issuing “pseudo-denials” that require pseudo-appeals before the MAO considers the denial formalized.

The practice is reported to be extremely widespread and used against non-contracted providers: small, often rural hospitals that tend to be more vulnerable to these tactics.

Reporting our lead story during the next live edition of Monitor Mondays will be Lisa Banker, MD, formerly chief medical advisor for revenue integrity at CarolinaEast Health System. Dr. Banker led the effort to convince CMS of the need to issue a recent memo on this topic.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports the latest news that’s happening at the intersection of COVID-19 and the SDoH.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

An Ominous Forecast: Auditors are Ramping Up Activities

Mon, 21 Sep 2020 13:00:00 -0400

The recent announcement by the Centers for Medicare & Medicaid Services (CMS) that it will be “ramping up” audits are quickly becoming a reality for providers across the country. Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), and Unified Program Integrity Contractor (UPIC) auditors are going full steam ahead, using data and analytics to assess overpayments via automated reviews – and new language in UPIC letters paints an ominous picture for providers they deem non-compliant.

Reporting the lead story during this edition of Monitor Mondays is Sean M. Weiss of DoctorsManagement, who addresses these issues and the steps necessary to ensure a level playing field.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen also conducts the Monitor Mondays Listeners Survey.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

The RVU Conundrum: Expect Declines in Operating Income

Mon, 14 Sep 2020 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) will reimburse a greater number of relative value units (RVUs) associated with office-based evaluation and management (E&M) visits, the agency announced recently.

In order to achieve budget neutrality, CMS will reduce the payment per RVU. With this change, CMS is allocating a larger proportion of its total spending to office-based physicians, at the expense of surgeons and hospital-based physicians.

Here’s the rub: organizations that utilize RVUs in their physician compensation arrangements and continue to pay the same 2020 rates per RVU on the increased number of 2021 RVUs will experience a dramatic decline in operating income. Reporting our lead story during this edition of Monitor Mondays is Adam J. Klein, who heads ECG’s Financial Services practice.

Other segments to be featured during the live broadcast include the following:

Whistleblower Update: Famed whistleblower Mary Inman, partner in the law office of Constantine Cannon, returns to the broadcast to report on two whistleblower cases that have dropped from the radar screen, but nevertheless are essential for re-examination.
RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

EXCLUSIVE: The Healthcare Algorithms Arms Race is Heating Up

Mon, 31 Aug 2020 13:00:00 -0400

Unlike the Cold War arms race between the then-Soviet Union and the United States, today’s arms race is being fought before computer monitors, and in the deep corners of computer laboratories. And the weapon of choice: algorithms.

This fierce fighting is taking place between auditors and providers, and the stakes are high: money. Lots of it.

No stranger to chronicling the former Cold War arms race, Edward Roche, RACmonitor’s investigative reporter, returns to the Monitor Mondays broadcast to report on how algorithms created by payers tend to foster a camouflage of mediocrity for providers.

Other segments to be featured during the podcast:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makesg his Monday Rounds with another installment of his popular segment.

Big Pharma versus 340B

Mon, 24 Aug 2020 14:00:00 -0400

In recent weeks, several major pharmaceutical manufacturers have taken actions that could lead to narrowing the 340B Drug Pricing Program, which provides outpatient drugs to safety-net hospitals, health centers, and clinics at discount prices. The savings are invested in care for patients with low incomes, living in rural communities.

The actions by Eli Lilly, Merck, and Sanofi are being challenged by a coalition of safety-net providers, including 340B Health, which represents more than 1,400 340B hospitals. Reporting our lead story during this edition of Monitor Mondays is Maureen Testoni, president and CEO of 340B Health, who will discuss why she is concerned by these actions by drugmakers.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

California Whistleblower Claim Yields $24 Million Abbvie Settlement

Mon, 17 Aug 2020 14:00:00 -0400

California is one of two states in the country that rewards whistleblowers for bringing forward information about private insurance fraud. A recent $24 million settlement with pharmaceutical giant Abbvie over the marketing of the company’s blockbuster drug, Humira, demonstrates the law’s effectiveness.

The settlement agreement was reached last week following allegations that the company violated California’s Insurance Frauds Prevention Act. Abbvie agreed to the settlement despite continuing to deny any wrongdoing.

On the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will provide details on this important news story.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Exclusive 60-Minute Broadcast: COVID-19 Rules

Mon, 10 Aug 2020 15:00:00 -0400

The omnipresent coronavirus pandemic continues to upend lives, from mundane occasions like grocery shopping to long-planned space exploration missions. The pandemic is manifesting itself from the halls of Congress to the cubicles at Centers for Medicare & Medicaid Services (CMS) headquarters, to classrooms, theatres, homes, and places of worship, among other venues.

On the next live edition of Monitor Mondays, we will explore the impact of the coronavirus on audits and auditing, proposed rules, guidance, and waivers.

Joining the broadcast to report on anticipated pandemic-related audits will be Dr. John K. Hall, founder of The Aegis Firm, a healthcare consulting firm. Dr. Hall, also an attorney, will discuss these types of scenarios, and how to prepare for the inevitable denials coming your way.

Also during the 60-minute broadcast, you’ll hear from Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Alpert Medical School of Brown University, who will provide a much-needed perspective on the impact of the prolonged epidemic. And making her debut appearance on Monitor Mondays will be Julia K. Brodt, PhD, an educator and former epidemiologst, who will provide a layperson’s background on antibodies, which are fundamental in the quest for a vaccine.

Other segments to be featured during the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SDoH.
Audit Report: Sean Weiss, compliance officer for DoctorsManagement, returns to the broadcast with the Monitor Mondays Audit Report.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
IRF Report: Angela Phillips, PT, president and chief executive officer for Image and Associates, reports on the the CMS final rule for the inpatient rehabilitation facility (IFR) prospective payment system for the 2021 fiscal year.

Special Edition: DateLine CMS

Thu, 06 Aug 2020 18:00:00 -0400

Center of Medicaid and Medicare Services (CMS) has been posting proposed rules for Medicare this past week. Already, CMS has issued the final rules for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, and Hospices; and we are still awaiting the final rule on the Inpatient Hospital payment rules.

In light of these proposed rules we’ve asked two experts, Dr. Ronald Hirsch and Terry Fletcher to explain the significance of these proposals in a special Friday edition of Monitor Mondays.

This special edition of Monitor Mondays was sponsored by Dr. Ronald Hirsch. You can visit his website here: https://www.ronaldhirsch.com/ or you can purchase his 'Hospital Guide to Contemporary Utilization Review, Second Edition' at https://hcmarketplace.com/contemporary-utilization-review

Defund the UPICs? Auditors Attack Osteopathic Medicine

Mon, 03 Aug 2020 13:00:00 -0400

While the battle cry of “defund the police” has emerged from Black Lives Matter activists following the death of George Floyd at the hands of Minneapolis police, could there also be sufficient reason for providers to advocate to “defund the Unified Program Integrity Contractors (UPICs)?”

According to RACmonitor investivative reporter Ed Roche, UPIC auditors are attacking osteopathic medicine, and might need lessons in reading patient notes. During the next live edition of Monitor Mondays, Roche will explore the seeming incompetence of auditors when they go after such providers. Osteopathic doctors help manage pain, but there may be no cure for an incompetent audit.

Other segments to be featured during the live broadcast include the following:

COVID-19 Report: Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Alpert Medical School of Brown University, will provide an update on the pandemic that claimed the lives of more that 152,000 in the U.S.
Audit Report: Sean Weiss, compliance officer for DoctorsManagement, will report on the latest wrinkle in the ongoing kerfuffle of telehealth and patient consent.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

The Virus and the Audits: A Special 60-Minute News Roundup

Tue, 28 Jul 2020 11:00:00 -0400

Two major storylines are discussed during this edition of Monitor Mondays, with the exclusive 60-minute broadcast to focus on the raging coronavirus pandemic and the imminent auditing of Medicare and Medicaid claims scheduled to begin Aug. 3, as directed by the Centers for Medicare & Medicaid Services (CMS).

Joining the broadcast to report on the coronavirus will be Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Alpert Medical School of Brown University. Offering an update on the imminent audits of Medicare and Medicaid claims will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. And Sean Weiss, chief compliance officer for DoctorsManagement, reports on the issues and implications associated with the public health emergency (PHE), which was extended recently by Alex Azar, Secretary of the U.S. Department of Health and Human Services (HHS).

Two reports from two provider organizations will round out the Monitor Mondays coverage of the impact of the deadly coronavirus on hospitals. Dennis Jones, administrator of patient financial services at Montefiore Nyack Hospital in Nyack, N.Y., once near the epicenter of the virus, reports on how his facility has emerged from the worst of the spike in the northeast. And Nicole Thorell, chief nursing officer at Lexington Regional Health Center, reports on how her rural hospital has managed to survive during the pandemic.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment. reporting on legal implications during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during this live broadcast to answer your questions.

Bagnall to Alexander- finally over? An assessment of Alexander V Azar on healthcare

Mon, 20 Jul 2020 12:00:00 -0400

Could Alexander VS. Azar really be over? This week's Monitor Mondays episode we've called upon or resident healthcare attorneys Knicole Emanuel Esq., David Glaser Esq. and our guest host John K. Hall MD, JD to dissect and assess the complicated case.

The case has been disorganized since the beginning, possibly leaving more questions than answers. This Monitor Mondays round table will analyze procedural aspects of the case and what it could potentially mean for providers, analyze where the decision has risk for providers, and provide guidance of how providers should respond in the future.

Other segments to be featured during the live weekly Internet radio broadcast include the following:

SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest research from the Urban Institute and Robert Wood Johnson Foundation about Unemployment, and Loss of Employer-sponsored insurance. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will have the latest legislative news coming from Washington.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Court Report: Mary Inman, Esq. has the latest report on Pfizer's charitable contributions and what future court rulings affect on the industry, and drug prices.

Cash and Lavish Goodies to Bribe Physicians to Prescribe Novartis Drugs: Anatomy of FCA Allegations

Mon, 13 Jul 2020 12:00:00 -0400

Last week, pharmaceutical giant Novartis paid $51 million to settle a Massachusetts suit about patient copay waivers. The DOJ press release notes that this is the 14th settlement of this kind to come from the Boston area. In related news, the Government brought a suit against Regeneron alleging that the company had a scheme of very well calculated charitable giving that steered patients to its macular degeneration drug, which costs $1,850 per dose, and away from a competitor’s drug, which costs $55 per dose.

We are joined this week by Mary Inman, Esq. who has the latest on the Novartis suit and the FCA Allegations and how the court rules might have expensive ripple effects on the industry, and on drug prices.

Other segments to be featured during the live weekly Internet radio broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the managed care plans that are addressing the SDoH amid COVID-19. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, now chief legislative affairs officer for Zelis, reports on the extension of PPP and new HHS guidance on CARES Act and cost-sharing for COVID-19 testing.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, joins the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

A Troubling Cornucopia of COVID-Related Fraud

Mon, 29 Jun 2020 14:00:00 -0400

The advent of the COVID-19 pandemic in the United States has generated nearly 2.5 million positive diagnoses, nearly 125,000 deaths – and dozens upon dozens of instances of modern-day snake-oil salesmen seeking to profit amid all of the chaos.

Presenting the lead story during this edition of Monitor Mondays is Edward M. Roche, who will describe the various ways in which federal authorities are looking to stamp out the opportunistic fraudsters.

Other segments to be featured in the podcast:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick,reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, reports on the status of key healthcare legislation.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, makes his Monday Rounds with another installment of his popular segment.

Respiratory Failure Denials could become more common, get ready for post-pandemic denials

Mon, 22 Jun 2020 14:00:00 -0400

Don't let your guard down, post COVID-19 respiratory failure denials are on the horizon. Andrea Taylor from Enjoin reports why we aren't seeing denials yet and tips for appeals and waivers.

Other segments featured during the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick reports on the National Health and Nutrition Examination Survey. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright reports on the status of key healthcare legislation and the healthcare provider relief fund.
Risky Business: Healthcare attorney David Glaser joins the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD makes his Monday Rounds with another installment of his popular segme

Exclusive: Post-Pandemic COVID-19 Audits and Denials

Mon, 15 Jun 2020 15:00:00 -0400

Welcome to the new normal. You and your team continue to be challenged by consequences of the coronavirus pandemic, dealing with PPE shortages, along with confusing and oftentimes contradictory guidance from the Centers for Medicare & Medicaid Services (CMS).

And now, we look onward – toward the audit horizon, and looming denials for COVID-related care. You need to be aware of ongoing payor expectations and potential risk areas for denials. Returning to Monitor Mondays to report our lead story during this edition of the weekly Internet radio broadcast will be Dr. John K. Hall, founder of The Aegis Firm, a healthcare consulting firm. Dr. Hall, also an attorney, discusses these types of scenarios, and how to prepare for the inevitable denials coming your way.

Other segments featured during the podcast:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, reports the news that’s happening at the intersection of COVID-19 and SDoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former CMS official Matthew Albright, reports on the status of key healthcare legislation.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, makes his Monday Rounds with another installment of his popular segment.

Exclusive: The Intersection of COVID-19 and Inpatient Rehabilitation Facilities

Mon, 08 Jun 2020 12:00:00 -0400

Faced with rising numbers of COVID-19 cases, one hospital struggled to find adequate medical/surgical beds due to the challenges it had with discharging COVID patients. With a strong desire to address the need for surge capacity and to meet patient needs for inpatient rehabilitation, the challenge was met by the team at Henry Ford Macomb Hospital in Michigan, as you’ll learn during this edition of Monitor Mondays.

Longtime RACmonitor contributor Angela Phillips will report on how the hospital kept the Inpatient Rehabilitation Facility (IRF) open, providing much-needed rehabilitation services while assisting the organization in meeting the needs of an influx of COVID patients and managing throughput to open acute beds as needed. Phillips, long considered be one of the nation’s foremost IRF authorities, is the president and CEO of Images & Associates.

Other segments featured on the podcast:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
Court Report: Famed whistleblower attorney Mary Inman reports on the recent court case that saw Med Analystic lose its battle to establish a new breed of corporate whistleblower outsiders.
SDoH Report: Ellen Fink-Samnick, reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment, reporting on risky business during the pandemic.
Monday Rounds: Ronald Hirsch, MD, makes his Monday Rounds with another installment of his popular segment.

Exclusive: COVID-19 and Contact Tracing

Mon, 01 Jun 2020 13:00:00 -0400

New York City-based RACmonitor investigative reporter Ed Roche returned to Monitor Mondays to report on developments in contact tracing: one of the newest tools in the fight to contain the deadly novel coronavirus that causes COVID-19.

A hefty amount of money is being invested in contact tracing, including the development of new automated tools. But Roche reports his concern that some of the models being proposed may complicate how we exercise our Constitutional right to privacy.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, reports on when HIPAA does, and does not, limit the ability to publicly comment on a situation like a Covid Outbreak during his Risky Business segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.1qq

Exclusive: Mitigating the Uncontrolled Spread of COVID-19: An Epicenter Case Study

Mon, 18 May 2020 14:00:00 -0400

Long-term care providers nationwide are seeking to identify ways to mitigate the uncontrolled spread of the COVID-19 virus amid vulnerable populations. Case in point: “drop teams” of physicians, infection preventionists, and nurses that could be deployed to any post-acute care space that was felt to be at risk.

After seeing an outbreak at LifeCare Center in Kirkland, Wash., physician leadership and case management at MultiCare in Spokane, Wash. brainstormed ways to prevent a similar local occurrence.

During this edition of Monitor Mondays MultiCare’s Ben Kartchner, MD, reports on how the drop teams are working in the region – offering lessons learned from one of the nation’s coronvirus hot spots.

Other segments on the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick reports on the news that’s happening at the intersection of COVID-19 and SDoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser joins the broadcast with his trademark segment, reporting on risky business during the pandemic.
Monday Rounds: Ronald Hirsch, MD makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays devoted additional time during the live broadcast to answer your questions.

Healthcare News Roundup: Special 60-Minute Edition

Mon, 11 May 2020 22:00:00 -0400

While much of today’s healthcare news is righty focused on the efforts to stave off the global coronavirus pandemic, there is other news to report – and Monitor Mondays will have a complete wrap-up on all of it during the next edition of the weekly Internet radio broadcast, while also looking ahead.

And given the tendency of the Centers for Medicare & Medicaid Services (CMS) to issue waivers and guidance with a unique style of ambiguity, a great deal of confusion also continues to come from hospitals and health systems in their efforts to remain compliant – while at the same time tending to their mission of delivering patient care amid the crisis. So during this special 60-minute live edition, we’ll also have our panelists standing by to answer your questions.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Monitor Mondays RAC Report.
Monday Focus: Kathy Pride, executive vice president of coding and documentation services for Panacea Health, will report on two interim final rules, including an expansion and relaxation of guidelines for telehealth services.
Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report on two prominent examples of the need for independent regulatory oversight: the removal of the Inspector General of the U.S. Department of Health and Human Services (HHS), and news that Rick Bright, former director of the Biomedical Advanced Research and Development Authority, has filed a whistleblower complaint with the Office of Special Counsel, claiming that he was transferred to a “less impactful position” at the National Institutes of Health (NIH) after he was reluctant to promote the use of drugs such as hydroxychloroquine to treat COVID-19 patients.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on regulatory ambiguity during the pandemic.
Outpatient Therapy Update: Nancy Beckley, president of Nancy Beckley and Associates, will return to the broadcast to report on inequities for outpatient therapy providers as it pertains to payment, reimbursement, telehealth, and service delivery.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
Special Report: RACmonitor investigative reporter Edward C. Roche, PhD, JD, will provide a status report on COVID-19 testing in the United States.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during this live broadcast to answer your questions. Returning to the broadcast will be Matt Lambert, MD, an emergency medicine physician and chief medical officer for Curation Health.

EXCLUSIVE: COVID-19 Town Hall – $50 Billion Aid Package: Pitfalls and Risks

Mon, 04 May 2020 16:00:00 -0400

Pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the U.S. Department of Health and Human Services (HHS) has allocated $50 billion to providers and other healthcare facilities in the form of a one-time payment, which does not need to be paid back.

The payment comes with terms and conditions that recipients must follow, however, including permissible uses for the payment – and failure to follow the terms and conditions, including documentation requirements, may result in an audit or other allegations of fraud and abuse.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick reports on the news that’s happening at the intersection of COVID-19 and SdoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative: Matthew Albright, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment, reporting on regulatory ambiguity during the pandemic.
Monday Rounds: Ronald Hirsch, MD, makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during this live broadcast to answer your questions.

EXCLUSIVE: A UM Dispatch from the Front Lines of the COVID-19 Pandemic

Mon, 27 Apr 2020 16:00:00 -0400

The global COVID-19 pandemic has presented a multitude of logistical challenges to healthcare providers across the country and beyond. But few are as daunting as the protocols utilization management (UM) directors are being asked to implement regarding patient status assignment.

Delivering a riveting report from the front lines of the pandemic during this edition of Monitor Mondays, Stephanie Van Zandt, MD, Medical Director and Physician Advisor with BayCare Health System, a nonprofit healthcare organization that connects Florida residents with services at 15 hospitals across the state.

Van Zandt describes the pitfalls and intricacies of the five-pronged policy she helped develop for BayCare as admissions continued to swell amid the pandemic, which has produced nearly 30,000 confirmed COVID-19 cases in the Sunshine State, along with nearly 1,000 deaths.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, reports on the news that’s happening at the intersection of COVID-19 and SdoH. Ellen also conducts the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment, reporting on telehealth and private payers during the pandemic.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays have devoted additional time during the broadcast to listener questions.

EXCLUSIVE: The COVID-19 Impact on Medicare Appeals

Mon, 20 Apr 2020 14:00:00 -0400

“Although Office of Medicare Hearings and Appeals (OMHA) office space is closed to the general public, OMHA remains open for business with employees working under maximum telework flexibilities, per U.S. Office of Personnel Management guidance.” -OMHA website.

Indeed, “OMHA hearings and appeals processing measures are proceeding as scheduled,” the notice reads. “Unless an appellant is notified directly that a hearing has been postponed or canceled, appellants should continue to appear for hearings by telephone, as scheduled.”

Through teleconferencing and phone calls, many administrative law judges (ALJs) are exercising flexibility in rescheduling such hearings or granting extensions to file for a hearing. Furthermore, the Centers for Medicare & Medicaid Services (CMS) has suspended new Medicare fee-for-service audits through the duration of the public health emergency, as you’ll hear more about during this edition of Monitor Mondays. Reporting our lead story during the weekly broadcast will be Andrew Wachler, Esq., a familiar figure at OMHA and managing partner of Wachler & Associates.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SdoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, joins the broadcast with his trademark segment, reporting on telehealth therapy.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during this live broadcast to answer your questions.

EXCLUSIVE: The COVID-19 Impact on Custodial Admissions

Mon, 13 Apr 2020 15:00:00 -0400

Custodial admissions are problematic for hospitals under normal circumstances. But now, incredible demands placed upon facilities by COVID-19 create even more challenges, as you’ll learn during the next edition of Monitor Mondays – when Juliet Ugarte Hopkins, MD, will return to the broadcast as its special guest to report on the issues that are hampering efforts to keep hospital beds open for the patients who require care for their medical conditions.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, files the Monitor Mondays RAC Report.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), reports on the news that’s happening at the intersection of COVID-19 and SdoH. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, reports on the status of healthcare legislation associated with the current COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, will join the broadcast with his trademark segment, in which he reports on the impact of COVID-19 on America’s teaching hospitals.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during the live broadcast to answer your questions. The COVID-19 Q&A is sponsored by Curation Health.

EXCLUSIVE: Hospitals on the Front Line – A Town Hall Q&A

Mon, 06 Apr 2020 15:00:00 -0400

The 1,000-bed USNS Comfort, a hospital ship that in the past has provided humanitarian relief around the world, is now anchored on Pier 90 in Manhattan to provide humanitarian relief as COVID-19, the illness caused by the novel coronarvirus, ravages New York City, now the epicenter of the pandemic. Also in New York City, the famed Jacob Javits Center has been converted to a 1,200-bed field hospital by the U.S. Army Corps of Engineers. In the meantime, the White House is warning the nation to expect the worst, reporting that up to 200,000 deaths from COVID-19 could occur. As President Trump put it, “this is going to be a very, very painful two weeks.”

The broadcast includes the following updates, and then segue to the town hall:

Alvin Gore, MD, CHCQM, is a physician advisor and director of utilization management at St. Joseph Health in Sonoma County, Calif, and also a member of the board of directors of the American College of Physician Advisors;
Matt Lambert, MD, an emergency medicine doctor and the chief medical officer (CMO) for Curation Health;
Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital in Nyack, N.Y., and a frequent panelist on Monitor Mondays and Talk Ten Tuesdays; and
Howard Stein, DO, MHA, CHCQM-PHYSADV, associate director of medical affairs and a senior physician advisor at CentraState Health System in Freehold, N.J.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on pending legislation in response to the COVID-19 pandemic.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

EXCLUSIVE: Monitor Mondays COVID-19 Town Hall Q&A

Mon, 30 Mar 2020 14:00:00 -0400

Waivers from regulations, dire shortages of ICU beds, and scarce personal protective equipment (PPE), including gloves, gowns, and masks, are all part of the new normal as the coronavirus (COVID-19) continues to generate global headlines, especially in the United States.

Amid a cacophony of misinformation, providers and patients are searching for clarity in this fog of war. That time has come. Next Monday, the long-running and authoritive voice of healthcare regulation, Monitor Mondays, will broadcast a live, 60-minute town hall, during which its panelists will answer your questions and those of your colleagues.
The broadcast rundown will include updates from the following, and then segue to the town hall.

Participating in the special news update will be the following:

Rural Health Crisis: The global pandemic that is the coronavirus is spreading to the wide-open spaces of rural America, threatening the very existence of hospitals, caregivers, and patients. Reporting on this crisis will be the vice president of government affairs and policy for the National Association of Rural Health, Brock Slabach.
RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Monitor Mondays RAC Report. Emanuel is expected to report on auditing activities by third-party auditors during COVID-19.
Audit Report: Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, will report on contingency planning during the pandemic.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on how hospitals should respond to the homeless population presenting in emergency departments during the COVID-19 crisis. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the $2 trillion COVID-19 economic stimulus deal passed by the Senate on Wednesday and expected to be voted on by the House on Friday.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers during the global pandemic, which has now resulted in more than 1,000 U.S, deaths.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

EXCLUSIVE: COVID-19 by the Numbers

Mon, 23 Mar 2020 15:00:00 -0400

During this of Monitor Mondays, senior healthcare analyst Frank Cohen, a computational statistician, reports on how anecdotal thinking is not evidence-based thinking, and it is difficult to draw conclusions without having all of the information – noting that’s exactly what is happening right now, as America grapples with the coronavirus (COVID-19).

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel files her Monitor Mondays RAC Report.
Audit Report: Sean M. Weiss, reports on the next audits you can expect to encounter.
SDoH Report: Ellen Fink-Samnick, has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright reports on current healthcare legislation – proposed, pending, or passed – and its intended consequences.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, makes his Monday Rounds with another installment of his popular segment which he discusses swing beds, Telehealth and billing under COVID19.

Converting Medicare Patients from Inpatient to Outpatient and Condition Code 44

Mon, 16 Mar 2020 15:00:00 -0400

Converting Medicare patients from inpatient to outpatient status is a compliance issue. And hospitals need to know how to process the proper billing level of care for beneficiaries. Using their benefits correctly is a responsibility, since these patients rely on caregivers to advocate for them.

To help navigate these potential audit traps, we asked Mary Beth Pace, vice president of care for Trinity Health, to be our special guest during this edition of Monitor Mondays.

Other segments to be featured on the podcast:

COVID-19 Update: Dennis Jones, director of patient financial services for Montefiore Nyack Hospital, reports on how the state of New York is working to remove barriers to the testing of the deadly virus.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, join the broadcast as a permanent guest and report on current healthcare legislation – proposed, pending, or passed – and its intended consequences.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Exclusive: Big Pharma, Big Money, Big Troubles

Mon, 09 Mar 2020 13:00:00 -0400

Seldom does a week pass without news about a pharmaceutical giant engaged in corporate wrongdoing. This week, the feds announced that they had filed a complaint under the False Claims Act (FCA) against Mallinckrodt ARD LLC. The complaint alleges that the pharmaceutical company “avoided paying hundreds of millions of dollars in Medicaid rebates due to significant drug price increases” as a result of “large increases in the price” of its drug H.P. Acthar Gel.

Recently, pharmaceutical company Sanofi-Aventis U.S., LLC, agreed to pay $11.85 million to resolve allegations that it violated the False Claims Act by paying kickbacks to Medicare patients through a purportedly independent charitable foundation, The Assistance Fund. And earlier, as reported by RACmonitor, electronic health records provider Practice Fusion Inc. agreed to pay a total of $145 million to resolve criminal charges and civil claims that it solicited and accepted unlawful kickbacks from pharmaceutical companies.

During this edition of Monitor Mondays, famed whistleblower attorney Mary Inman continues her reporting on the misdeeds of big pharma, with an update on the aforementioned Sanofi-Aventis FCA case.

Other segments to be featured during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, files the Monitor Mondays RAC Report.
Audit Report: Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reports on the next audits you can expect to encounter.
Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis reports on current healthcare legislation – proposed, pending, or passed, and its intended consequences.
Risky Business: Healthcare attorney David Glaser, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD makes his Monday Rounds with another installment of his popular segment.

Hospital Price Transparency: Clearing Up the Compliance Confusion

Mon, 02 Mar 2020 13:00:00 -0500

Contentious and confusing, the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule will become effective Jan. 1, 2021.

On the surface, the requirements are straightforward: hospitals and health systems must make accessible all negotiated managed care rates in a machine-readable format, along with a list of 300 “shoppable” items –non-urgent, high-volume items and services – on their website or via an interactive tool for consumers. But below the surface lurks confusion. That is why we asked Frederick Stodolak, the president of Panacea Healthcare and a subject matter expert on hospital pricing, to be our special guest during this edition of Monitor Mondays.

Other segments featured on the podcast:

Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will join the broadcast as a permanent guest and reports on current healthcare legislation: either proposed, pending, or passed, and its anticipated consequences.
RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors.
SDoH Report: Ellen Fink-Samnick, has the latest on the social determinants of health (SDoH) specifically with pediatrics.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Exclusive: The Plight of Rural Health, Part II

Mon, 24 Feb 2020 12:00:00 -0500

Like a destructive earthquake, recent news from The Chartis Center for Rural, documenting the accelerated rate of closures among rural hospitals, is sending shock waves through rural communities.

As with the Richter scale, the closure of one rural hospital is likely to have an exponential impact on all rural health. And the stark reality is that, as of January 2020, a total of 120 rural health facilities have closed their doors.

Leslie Marsh, the chief executive of Lexington Regional Health Center in Lincoln, Neb., returns to Monitor Mondays and reports on precipitous peril for rural hospitals, which is now rising to a national disaster.

Other segments featured on the podcast are:

RAC Report: Senior healthcare analyst Frank Cohen returns to the broadcast to report on why Recovery Audit Contractors (RACs) can’t be considered unbiased in a court of law.
Audit Report: Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reports Artificial Intelligence (AI) and its impact on compliance and auditing.
Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrickson & Bryon, will join the broadcast with his trademark segment Risky Business.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Exclusive: The Plight of Rural Health, Part I

Mon, 17 Feb 2020 12:00:00 -0500

With a 30,000-foot view of rural healthcare policies and regulations emanating from Washington, D.C., Leslie Marsh still recognizes the importance of having boots on the ground, serving as the chief executive of Lexington Regional Health Center in Lincoln, Neb.

Marsh, who also serves as vice president of board of directors for the ruralMED Health Network, addresses the ubiquitous Z codes and their impact on the rural population, among other serious issues facing rural healthcare providers, during this edition of Monitor Mondays.

Other segments to be featured during the podcast includes:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors.
Audit Report: Sean M. Weiss, partner, and chief compliance officer for DoctorsManagement, reports the latest on Target Probe Educate.
SDoH Report: Ellen Fink-Samnick has the latest news on rural health and also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser has his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Exclusive: The AI Arms Race in Medicare Audits

Mon, 10 Feb 2020 13:00:00 -0500

The artificial intelligence (AI) arms race is heating up. The use of AI by healthcare providers responding to a wave of audits initiated by AI systems is an escalation. As the government continues to deploy AI systems in Medicare audits, providers will respond with their own counter-measures, also using AI. Reporting our lead story during the next edition of Monitor Mondays will be RACmonitor investigative reporter Edward Roche, who continues to monitor the intensifying showdown.

Other segments to be featured on the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Audit Report: Sean M. Weiss, partner, and chief compliance officer for DoctorsManagement, reports on the latest audits you can expect to encounter.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrickson & Bryon, joins the broadcast with his trademark segment, which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

War on Drugs: EHR Vendor Admits to Receiving Illegal Kickbacks from Opioid Pharmas

Mon, 03 Feb 2020 13:00:00 -0500

Practice Function, Inc., a unit of Allscripts Healthcare Solutions Inc., engaged in an "abhorrent" scheme to help a pharmaceutical company push its extended-release opioids, according to a news release posted on Monday by the U.S. Department of Justice.

The company agreed to pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software. Practice Fusion admitted soliciting and receiving kickbacks from a major opioid company in exchange for utilizing its EHR software to influence physician prescribing of opioid pain medications. Famed whistleblower attorney Mary Inman reports our lead story this edition of Monitor Mondays.

Other segments to be featured on the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
IRF Report: Angela Phillips, considered to be among the nation’s most recognized authorities on inpatient rehabilitation facilities (IRFs), provides a 2020 update on the many changes taking in place in the IRF world.
SDoH Report: Ellen Fink-Samnick, has the latest news on social determinants of health (SDoH) and also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, joins the broadcast with his trademark segment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Balancing Billing: A Swirling Controversy

Mon, 27 Jan 2020 13:00:00 -0500

What once appeared to be a legislative slam dunk is now mired in controversy, this time fueled by the recently formed coalition dead-set against the proposed use benchmark payments.

The Coalition Against Rate-Setting considers the practice tantamount to price-fixing. What will happen next to the compromise legislation, which was hammered out with bipartisan congressional support? Matthew Albright, chief legislative affairs officer for Zelis, reports our lead story during this edition of Monitor Mondays.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Audit Report: Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reports on the latest audits you can expect to encounter. Weiss joins the broadcast as a regular panelist, reporting on the ever-changing audit landscape.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducted the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson & Bryon, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

War on Drugs: Court Orders AmerisourceBergen to Hand Over Opioid-Related Documents to Pension Fund

Mon, 20 Jan 2020 13:00:00 -0500

AmerisourceBergen, one of the nation’s largest pharmaceutical wholesalers, must turn over records to pension fund shareholders probing to determine wrongdoing by the drug distributor’s board for the company’s multi-billion-dollar legal exposure from the nationwide opioid crisis.

AmerisourceBergen was already facing two congressional investigations, plus a Drug Enforcement Administration (DEA) probe. Reporting on this developing story is famed whistleblower attorney Mary Inman, a partner in the London law office of Constantine Cannon.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors.
Audit Report: Sean M. Weiss, partner, and chief compliance officer for DoctorsManagement, reports on the latest audits you can expect to encounter.
SDoH Report: Ellen Fink-Samnick has the latest news on a report from NPR about life experience and income inequality in the USA. Ellen will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment where he will discuss the new Important Message from Medicare.

2020: Look Out, Look Ahead

Mon, 13 Jan 2020 14:00:00 -0500

2020 ushers in a formidable decade of healthcare regulations and a perilous audit landscape, populated with aggressive auditors who will be aided by artificial intelligence to review and deny claims.

Decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and through this new and unchartered decade.

Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2020, during the first broadcast of the year for the weekly Internet broadcast, which is celebrating 10 years of live programs. Our line up of panelists includes:

Dr. Ronald Hirsch, MD, FACP, CHCQM
Nancy Beckley, MS, MBA, CHC
Knicole Emanuel, Esq.
Maureen Testoni, Esq.
Stanley Nachimson, MS
Edward M. Roche, PhD, JD
Andrew Wachler, Esq.
Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Angela M. Phillips, PT
William A. Dombi, Esq.
Leslie Marsh, RN, BS, MSN, MBA

Monitor Mondays 10th Anniversary Tribute

Mon, 06 Jan 2020 15:00:00 -0500

Join us for a unique look behind the scenes with long-time Monitor Mondays moderator Clark Anthony as he interviews many of our esteemed panelists from the last 10 years.

Home Health and Hospice: State of the Union

Mon, 09 Dec 2019 13:00:00 -0500

It’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare & Medicaid Services (CMS) included a reduction in the base payment rate of 8.01 percent in the Patient-Driven Groupings Model (PDGM) of the 2020 Home Health Prospective Payment System Rate Update.

Returning to Monitor Mondays is William Dombi, president of the National Association for Home Care and Hospice, who will provide a regulatory update for his association as its members prepare for another year of audits.

Other segments to be featured on the broadcast include the following:

Monday Focus: What are likely to be three major audit issues in 2020? Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reveals his pick of the top challenges you and your team will face in 2020.
RAC Report: Healthcare attorney Knicole Emanuel reports on the latest activities by the Recovery Audit Contractors (RACs) and other third-party Medicare claims auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, unveils his 2019 Hirsch’s Heroes: individuals who, in his judgment, made outstanding contributions in the world of healthcare over the last year.

Rural Health: State of the Union

Mon, 02 Dec 2019 13:00:00 -0500

Rural hospitals are an endangered species in America, with extinction a real possibility.

In fact, the North Carolina Rural Health Research and Policy Analysis Center report that more than 120 hospitals have closed nationwide since 2005, with nearly 70 percent (or 83) of those closures occurring since 2010. Adding insult to injury is the recent announcement from the Centers for Medicare & Medicaid Services (CMS) that Monday, Dec. 2 is the deadline for critical access hospitals (CAHs) to submit a hardship exception to avoid the “Medicare downward payments.” To qualify, those hospitals must illustrate the use of certified electronic health record technology (CEHRT) in order to meet the reporting requirements of the Medicare Promoting Interoperability Program and demonstrate “meaningful” use.

Delivering a State of the Union report on America’s rural hospitals during this edition of Monitor Mondays will be Maggie Elehwany, vice president of government affairs and policy for the National Rural Health Association.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel will report on the latest activities by the Recovery Audit Contractors (RACs), and other third-party Medicare claims auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Court Report: The U.S. Supreme Court recently turned away two cases that tested the scope of the False Claims Act. Reporting this story will be famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon.
Risky Business: Healthcare attorney David Glaser will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Discharge Planning Conditions of Participation: The IMPACT and Consequences

Tue, 26 Nov 2019 09:00:00 -0500

Many hospitals are likely in the throes of preparing to implement the Centers for Medicare & Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, including how to reconcile the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The new rule becomes effective Friday, Nov. 29, 2019.

“CMS has spent the last two years working on the IMPACT Act, and they are now ready to implement,” reports Mary Beth Pace, vice president of care management at Trinity Health. “Does the CoP resemble anything akin to what you thought they would come out with? It does not to us. Let me reflect on our initial shock, and then our action.”

For a field report on how one major health system is preparing for this major new policy, RACmonitor has invited Ms. Pace to be the special guest during the next edition of Monitor Mondays.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel will report on the status of the Medicaid lawsuit filed after more than two dozen plaintiff Virginia behavioral healthcare providers had their managed care contracts terminated by six defendant managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Fraud Report: The manager of multiple medical clinics in Brooklyn and Queens, New York, was found guilty for his role in a nearly $100 million healthcare kickback and money laundering scheme, according the U.S. Department of Justice. Reporting this story will be famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon.
Risky Business: Healthcare attorney David Glaser will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Monitoring Patient Mortality: Compliance and Quality

Mon, 18 Nov 2019 12:00:00 -0500

Patient mortality is closely monitored. If a patient dies, the hospital wants to be sure the documentation accurately portrays the acuity of the patient, with all diagnoses, so that when the risk of mortality is calculated with the complex algorithm used by federal agencies, it demonstrates that the death was not unexpected, and is not indicative of poor-quality care.

Reporting the lead story during this episode of Monitor Mondays is Melinda Battaile, MD, physician advisor and clinical documentation advisor for Vidant Health in Greenville, N.C.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit filed after more than two dozen plaintiff Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs).
Monday Focus: Algorithms are a trending topic, made even more so with recent accusations of gender bias in the Goldman Sachs Apple Card leveled by presidential candidate and U.S. Senator Elizabeth Warren. RACmonitor investigative reporter and New York attorney Ed Roche returns to the broadcast to continue his reporting on algorithms and their use in claims auditing.
Policy Update: The Centers for Medicare & Medicaid Services (CMS) intends to press forward with payment cuts for some hospital clinic visits, as well as cuts to the 340B drug discount program, despite an adverse court ruling in September. Matthew Albright, chief legislative affairs officer for Zelis, reports on this developing story.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on CMS's final rule’s reference to “shoppable” services.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Known by the Company You Keep: Disclosures of Affiliations

Mon, 11 Nov 2019 12:00:00 -0500

Direct or indirect past affiliation with an individual the Centers for Medicare & Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare.

The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, waste, or abuse.

Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates. Mr. Wachler also discusses what constitutes an “affiliated entity” and what events must be disclosed.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Court Report: Famed whistleblower attorney Mary Inman reports on Tenet Healthcare’s proposed $66 million False Claims Act settlement. Inman is a partner in the London office of Constantine Cannon.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducted the Monitor Mondays Listener Survey.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Anatomy of an Algorithm: Optum Algorithm Under Fire for Alleged Racial Bias

Mon, 04 Nov 2019 13:00:00 -0500

Giant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable.

The results of a study published last week by Science revealed what researchers identified as a "significant racial bias" in Optum’s algorithm, which reportedly undervalues the healthcare needs of black patients. Although Science didn’t mention Optum by name, other news organizations have confirmed that it was, indeed, Optum.

Reporting on this developing story during this edition of Monitor Mondays is RACmonitor investigative reporter and New York attorney Edward Roche, director of business intelligence for Barraclough New York LLC.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Ring of Fire: Dr. Alvin Gore, the physician advisor at St. Joseph Health in Santa Rose, Calif., reports on disaster planning in the wake of horrific wildfires burning out of control in Northern California. Shortages of nurses who were ordered to evacuate is one of the many emergencies he continues to monitor as the fire rages.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Monday Rounds: Substituting for Dr. Ronald Hirsch, is Dr. Howard Stein, associate director of medical affairs and physician advisor in care management at CentraState Medical Center in Freehold, New Jersey.

CMS Site-Neutral Payments: Hospitals Win, CMS Loses, but the War is Not Over

Mon, 28 Oct 2019 13:00:00 -0400

A federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings. The Centers for Medicare & Medicaid Services (CMS) could appeal the court’s decision on its site-neutral payment rule for hospital outpatient services. Score one for hospitals, but the war is far from over.

Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
E&M Coding Changes: Impending evaluation and management (E&M) changes for 2021 and their impact on coding and compliance professionals is reported by Shannon DeConda, founder and president of NAMAS.
Monday Focus: Ransomware: Healthcare news has been rife with stories of bad actors from overseas planting ransomware in the business systems of hospitals and medical practices large and small. Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, reports on this ongoing problem and offers advice providers can take to mitigate the risk of global hackers.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Feds Putting the Squeeze on Medicare and Medicaid Payments: $252.6 Billion in Cuts Reported

Mon, 21 Oct 2019 15:00:00 -0400

Acts of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American Hospital Association (AHA) and the Federation of American Hospitals.

Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
War on Drugs: Famed whistleblower attorney Mary Inman, partner at the London law office of Constantine Cannon, reports that major drug manufacturers and distributors are proposing deals that could be worth up to $50 billion to help resolve the nationwide litigation of the pharmaceutical industry’s liability for America’s opioid crisis.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
- Resources from Ellen Success over Stress, DePaul University Grant, Robert Wood Johnson Foundation Grant to Purpose Built Communities, CVS Funding
Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his trademark segment in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

PDPM: New Reimbursement Model is Driving Disruption

Mon, 14 Oct 2019 12:00:00 -0400

There have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS): the Patient-Driven Payment Model.

Reporting on these new changes during this edition of Monitor Mondays will be Toby S. Edelman, senior policy attorney for the Center for Medicare Advocacy. The new PDPM system reverses the financial incentives that existed for 20 years. Instead of paying more money for more minutes of therapy that a resident at a SNF receives, the new system pays less for residents who receive therapy. Ms. Edelman will discuss how the reimbursement system has changed, and what residents and their families can do to try to ensure that patients continue to receive medically necessary therapy.

Other segments to be featured on the broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Washington Report: President Donald Trump’s recent executive order tweaking the Medicare system continues to roil healthcare stakeholders. Reporting on the ongoing fallout is Matthew Albright, chief legislative affairs officer for Zelis Healthcare and former CMS official.
Monday Focus: New York attorney and RACmonitor investigative reporter Ed Roche returns to the broadcast to report on the use of artificial intelligence in Medicare audits, as announced in the President’s executive order.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers. HHS Proposes Stark Law Anti-Kickback Statue Reforms
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. Medical Conservative

340B Drug Program in CMS Crosshairs

Mon, 07 Oct 2019 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program.

How will the information gathered by CMS be used, moving forward? And why is this action being taken by CMS? The agency has a history of attempted cuts to 340B reimbursement; the most recent such action by CMS occurred last December, after which a federal judge ruled against the move.

Reporting our lead story during this edition of Monitor Mondays is Maureen Testoni, president and CEO of 340B Health.

Other segments featured on this episode include:

Court Report: Federal law enforcement personnel recently took down a fraudulent scheme involving 35 defendants associated with telemedicine companies and cancer genetic testing laboratories. The defendants have been charged for their alleged participation in fraudulently billing Medicare more than $2.1 billion for CGx tests. Reporting this story is famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon.
RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays to report on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Developing Story: Virginia Governor and MCOs Sued by Behavioral Health Providers

Mon, 30 Sep 2019 13:00:00 -0400

As expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause.

The suit was filed by the Potomac Law Group.

During this edition of Monitor Mondays, healthcare attorney Knicole Emanuel, a partner in the aforementioned law firm and a member of the RACmonitor editorial board, provides an update on the lawsuit as it makes its way through the court system.

Also covered in this edition of Monitor Mondays:

SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Monday Focus: A listener reports that Noridian (Jurisdiction F), rather than providing any diagnosis codes for non-dialysis usage, insists on having five scenarios provided in order to determine if an order meets guidance criteria. Attorney and physician Dr. John Hall weighs in on this topic, which seems to have entangled front desk staff, schedulers, and physicians.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Developing Story: Virginia’s Behavioral Health Providers Under Siege

Mon, 23 Sep 2019 12:00:00 -0400

Other segments to appear during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel reports our lead story on the mass terminations of behavioral healthcare providers in Virginia. Emanuel has also been at ground zero in Richmond this past week, representing the aforementioned association there. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Monday Focus: Physician advisors should spend their time talking to doctors, not reviewing records and writing lengthy status determinations, according to Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., returns to the broadcast to report on the consequences that arise when internal physician advisors merely sit behind their computer screens, to the exclusion of interactions with other physicians.
Risky Business: Healthcare attorney David Glaser continues his reporting on the dramatic and long-awaited outcome of the recent court decision involving AsceraCare – a decision that appears to make it difficult to make a False Claims Act case based on physician judgment.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

No Time for SNFs: PDPM Becomes Effective Oct. 1

Mon, 16 Sep 2019 13:00:00 -0400

Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM). Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to avoid a Recovery Audit Contractor (RAC) audit.

Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel.

Other segments to appear during the live broadcast include the following:

CMS Report: The Centers for Medicare & Medicaid Services (CMS) is cracking down on bad actors: past and present fraudsters. Author, educator, and consultant Duane Abbey, president of Abbey and Abbey Consultants, Inc., reports on CMS efforts to identify those who are or have been affiliated with illegitimate providers.
Surprise Balance Billing: While it once appeared to be a done deal leading into the August recess for members of Congress, legislative action on surprise balance billing has stalled out as stakeholders and lawmakers struggle with the details. An update on this now-contentious issue is presented by Matthew Albright, chief legislative affairs officer for Zelis Healthcare and former CMS official.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has latest news on this trending topic that is attracting significant media attention.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

RACs and SNFs: Referrals in the Crosshairs

Mon, 09 Sep 2019 14:00:00 -0400

Do you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)?

You need to know because the Recovery Audit Contractors (RACs) and other contractors are reviewing SNF referrals. Reporting our lead story is physician and attorney John K. Hall, founder of the Aegis Firm. Hall reviews such statutory and regulatory requirements while also making recommendations for audit readiness.

Other segments to appear during the broadcast:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report the latest audits by RACs and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Hurricane Watch: Dr. Daniel Zirkman, the chief physician advisor at CarolinaEast Medical Center in New Bern, N.C., reports on how his facility prepared for Hurricane Dorian, which forced the mandatory evacuation of nearly 400,000 residents in that state.
SDoH Report: Marvin D. Mitchell, Director of Case Management and Social Services at San Gorgonio Memorial Hospital in Banning, Calif., east of Los Angeles, reports on how to operationalize social determinants of health (SdoH) concepts.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Understanding the Rules of Engagement at the ALJ Level

Mon, 26 Aug 2019 13:00:00 -0400

Despite an order from the U.S. District Court for the District of Columbia for the federal government to reduce the backlog of Medicare appeals, the requirements for victory in front of an Administrative Law Judge (ALJ) remain the same.

During this edition of Monitor Mondays, David Mullens, a California healthcare attorney, will address some of those fundamentals.

Other segments to appear during the podcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Court Report: Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, reports on the latest development in the False Claims Act lawsuit filed by Integra Med Analytics last year against Providence St. Joseph Health. Inman previously reported on this story last August, noting that Integra was seeking $188.1 million related to alleged upcoding of Medicare claims.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey. Click here for Ellens resource
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Two Suicides and a Bankruptcy: Have Some Auditors Gone Rogue?

Mon, 19 Aug 2019 12:00:00 -0400

Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable tragedy.

RACmonitor Editorial Board member, investigative reporter, and New York attorney Edward Roche returns Monitor Mondays with this exclusive story about a durable medical equipment (DME) provider facing auditors who, in his words, had gone rogue.

Other segments to appear during the live broadcast include the following:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
The Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports on a controversial decision made last week, when U.S. District Judge David Ezra, sitting in Texas, dismissed a whistleblower’s complaint alleging that an executive with Baylor University Medical Center created an upcoding scheme to overcharge Medicare.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. See Ellens Survey Results
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

An Unsolved Mystery: Lifting the Suspension of Medicare Funds

Mon, 12 Aug 2019 13:00:00 -0400

Obtaining an injunction in federal court to lift a suspension of access to Medicare or Medicaid funds is rare, according to healthcare attorney Knicole Emanuel.

As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons that might explain such a mystery during this edition of Monitor Mondays.

Other segments to appear includes:

IRF Report: Angela Phillips, considered to be one of the nation’s foremost authorities on inpatient rehabilitation facilities (IRFs), reports on the final rule for the IRF prospective payment system for the 2020 fiscal year.
The Court Report: Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, reports on a $57 million fraud scheme that involved laundering money through a hospital.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Changes in the Works for Home Care Providers

Mon, 05 Aug 2019 13:00:00 -0400

The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the institution – and obviously, the referral from the community will have a lower payment.

Judith A. Stein, JD, executive director of the Center for Medicare Advocacy, reports on this story, along with William Dombi, Esq. president of the National Association of Home Care and Hospice, during this edition of Monitor Mondays.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, and will report on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Medicare Advantage Plans: Making Up Their Own Rules

Mon, 29 Jul 2019 12:00:00 -0400

Reports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare.

Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.”

This is but one example of Medicare Advantage (MA) plans misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care they provide to their members. Reporting on this development during this edition of Monitor Mondays is Steve Phillipson, Director of Hospital Medicine at Aspirus Wausau Hospital, in Wausau, Wis.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Monday Focus: Marvin D. Mitchell, Director of Case Management and Social Services at San Gorgonio Memorial Hospital in Banning, Calif., east of Los Angeles, reports on the potentially adverse issues associated with “copy-and-paste” functionality in electronic medical records (EMRs).
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Auditors Will Target SNF Patient Condition, Not Services and Time Rendered

Mon, 22 Jul 2019 12:00:00 -0400

There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits.

Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documentation can easily lead to higher reimbursement – and the likelihood of audits leading to claim denials.

Reporting on this development during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.

Other segments to appear during broadcast include:

Court Report: The Reckitt Benckiser Group has agreed to pay $1.4 billion to resolve its potential criminal and civil liability related to a federal investigation of the marketing of the opioid addiction treatment drug Suboxone. Whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports on how an addiction specialist filed a False Claims Act (FCA) motion leading to the largest settlement in U.S. history related to the opioid crisis.
Monday Focus: Senior healthcare analyst Frank Cohen returns to Monitor Mondays with a unique perspective on artificial intelligence (AI). Cohen reports on how the more accurate term for the ubiquitous AI should be “augmented intelligence,” as it relates to non-clinical areas of healthcare.
SDoH Report: Ellen Fink-Samnick, nationally recognized expert on the social determinants of health (SdoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

What to Do When a Government Agent Knocks on Your Door

Mon, 15 Jul 2019 12:00:00 -0400

An older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records.

In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary fines and penalties. What could have possibly triggered this investigation?

Reporting this developing story during this edition of Monitor Mondays is Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS). DeConda, who personally talked to the rural West Virginia physician, will report on the latest development in the case of a healthcare professional who plans to tell a jury of his peers that he didn’t swindle Medicare for money at their expense.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Monday Focus: John K. Hall, MD continues his reporting on the now-infamous blog post of May 2, by Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator. Hall reports that he expects that providers can expect more Recovery Audit Contractor (RAC) audits as a result of her blog. Hall is the founder of the Aegis Firm.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on Split Shared Evaluation and Management EM Services.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

The Seema Verma Blog Post That’s Making Providers Anxious

Mon, 08 Jul 2019 12:00:00 -0400

Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on the volume of claims? Reporting this developing story during the next edition of Monitor Monday will be John K. Hall, MD, founder of The Aegis Firm.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel will return to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
Monday Focus: Several different trends are simultaneously affecting physician payment even delimiting consideration to the Medicare program. Reporting on these trends and their impact on physician reimbursement and compliance requirements will the author, educator and consultant Duane Abbey, president of Abbey & Abbey Consultants, Inc.
Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

340B Drug Survey Reveals Help to Rural Hospitals

Mon, 01 Jul 2019 13:00:00 -0400

Under siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey.

Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey results and the import of its findings during this edition of Monitor Mondays Maureen Testoni, president and CEO for 340B Health.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention.
Monday Focus: A recent study by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has revealed a concerning series of findings related to the under-reporting of instances of potential abuse and neglect of elderly Medicare patients. Reporting on this developing story is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States.
Case Managers at Risk: Complaints associated with discharge planning can involve allegations that a patient was discharged before they were medically stable enough to leave the hospital, or that services or supplies required in the outpatient setting were not provided. These and other incidents point to the legal liability of case managers. Reporting this developing story is Juliet Ugarte Hopkins, MD, physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Yea or Nay? Surprise Balance Billing Legislation Heads for a Vote

Mon, 24 Jun 2019 13:00:00 -0400

U.S. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health Committee, appears to be ready to shepherd his 165-page draft legislation on surprise balance billing for a vote next week.

In their push to get legislation prohibiting such billing through before the August recess, both the House and Senate have held hearings in the past two weeks on the various approaches to the problem. Those hearings have made the industry battle lines clearer, in terms of how the various industry sectors think that out-of-network providers should be compensated by payors.

Although no single approach appears to be significantly favored at this point, Matthew Albright, former Centers for Medicare & Medicaid Services (CMS) official reports the lead story during this edition of Monitor Mondays.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention.
CMS/IRF Settlement: As reported by RACmonitor, the Centers for Medicare & Medicaid Services (CMS) agreed last week to settle appeals for inpatient rehabilitation facilities (IRFs) following a two-year dispute with the industry. Reporting on this developing story will be Angela Phillips, president of Images & Associates, and one of the nation’s foremost IRF authorities.
- Links from Ellen's segment: Commonwealth Fund, Kaiser Family Foundation 1, Kaiser Family Foundation 2, Harvard TH Chan School of Public Health, Medicaid Work Requirements Chart
News from OMHA: The Office of Medicare Hearings and Appeals (OMHA) has expanded its Settlement Conference Facilitation (SCF) program, and it is now open to the appellant community. Healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates, reports on how these expanded eligibility requirements provide new opportunities for appellants.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Links from David's segment:
- Supreme Court Case that says CMS must follow a more stringent process for issuing new rules than the Administrative Procedure Act requires.
- Fraud Alert: Genetic Testing Scam
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Responding to Emergency Department Claim Denials

Mon, 17 Jun 2019 13:00:00 -0400

Most likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years.

But how can you and your team effectively deal with them? What tools and techniques are available?

During this edition of Monitor Mondays, John K. Hall, MD, founder of The Aegis Firm and the newest member of the RACmonitor editorial board, will make his debut appearance on the broadcast to report on how payers are denying claims and how best to avoid them.

Other segments to appear during the live broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
False Claims Act Report: The U.S. Attorney’s Office in Chicago announced this week that a Chicago-area physical therapy center and four nursing facilities have agreed to pay $9.7 million to resolve civil allegations that they violated the False Claims Act by providing unnecessary services to increase Medicare payments. The owner of the skilled therapy service provider was excluded from the Medicare program for five years. On hand to explain the significance of this unusual case will be famed whistleblower Mary Inman, partner in the London office of Constantine Cannon.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds with another installment of his popular segment.

A Legend Returns to Monitor Mondays

Mon, 10 Jun 2019 15:00:00 -0400

Daniel Levinson, former head of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), will make his first broadcast appearance on Monitor Mondays since his announced retirement earlier this year.

During his 15-year stint as the nation’s top healthcare watchdog, Levinson oversaw investigations into controversial health issues, including what was described as the largest healthcare fraud takedown in history in July 2017, when more than 400 defendants in 41 judicial districts were charged with participating in schemes involving about $1.3 billion in false billings to Medicare and Medicaid.

Other segments to appear on the broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
Court Report: Reporting on the major Insys Therapeutics settlement announced Thursday is famed whistleblower Mary Inman, a partner in the London office of Constantine Cannon.
Monday Focus: The U.S. House of Representatives Ways and Means Committee will hold a hearing next Wednesday on "Medicare for All," the proposal that would shift the U.S. to a single-payer healthcare system. Continuing his reporting on this hot-button topic will be Dennis Jones, administrator of patient financial services at Montefiore Nyack Hospital in Nyack, N.Y.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

No Surprise: Stakeholders Fight to Solve Surprise Billing

Mon, 03 Jun 2019 14:00:00 -0400

The fight is on, and combatants are sparring over how to implement a legislative ban on surprise balance billing.

In recent congressional testimony, providers, payers, and hospitals have clashed on how to keep patients from being stuck with huge expenses, with each side blaming the other for being intransigent. One of the major issues is how out-of-network doctors should be reimbursed, and at what rate.

Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis and the former Director of the Administrative Simplification Group of the Centers for Medicare & Medicaid Services (CMS).

Other segments to appear on the broadcast include:

RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. Emanuel begins this broadcast as a permanent Monitor Mondays panelist.
Court Report: Intermountain Healthcare recently settled a high-profile case alleging unnecessary heart procedures. On hand to explain the significance of this case is famed whistleblower Mary Inman, a partner in the London office of Constantine Cannon.
SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), returns to the broadcast as a permanent panelist. And in this edition of Monitor Mondays, she will explain why so many consultants appear to be jumping on the SDoH bandwagon – and why this could be problematic.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

340B Dodges Another Bullet

Mon, 20 May 2019 13:00:00 -0400

A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program.

U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association v. Alex M. Azar, HHS Secretary, ordering HHS back to the drawing board and warning it to act with haste to make a correction.

Reporting our lead story during this edition of Monitor Mondays is RACmonitor national correspondent Timothy Powell.

Other segments to appear on the broadcast include:

Court Report: Two more pharmaceutical companies have agreed to pay $125 million to resolve allegations that they paid kickbacks through co-pay assistance foundations. Famed whistleblower attorney Mary Inman has an update on this story, which she first reported on April 15. Inman is a partner in the London office of Constantine Cannon.
Monday Focus: What are the issues when trying to project the results of an audit to a larger population of providers? Senior healthcare analyst Frank Cohen with DoctorsManagement reports on the myth surrounding pass/fail rates for providers.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
- Link for Davids segment: The new guidance about co-location of space in hospital-based space, New DOJ guidance about Cooperation in False Claims Act Cases
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.
- Links for Dr. Hirsch's segment: PREOPERATIVE MEDICAL TESTING BEFORE CATARACT SURGERY, Reduce Low-Value Preoperative Care

Inpatient versus Outpatient: Status of Psych Patients in the ED

Mon, 13 May 2019 12:00:00 -0400

Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and frustration.

Reporting our lead story during this edition of Monitor Mondays is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States in partnership with hospitals and health systems. Dr. Seward is a recent addition to the RACmonitor editorial board.

Other segments to appear on the broadcast include:

Program Integrity Issues: Healthcare attorney Andrew Wachler, a managing partner at Wachler & Associates, reports on Center for Program Integrity (CPI) priorities for 2018 and 2019, including remarks on the various contractors and their methodologies.
Court Report: US WorldMeds (USWM) LLC has agreed to pay $17.5 million to resolve allegations that it violated the False Claims Act by paying kickbacks to patients and physicians to improperly induce prescriptions of its drugs, Apokyn®, and Myobloc®. USWM is a pharmaceutical manufacturer headquartered in Louisville, KY. Famed whistleblower attorney Mary Inman reports this developing story. Inman is a partner in the London office of Constantine Cannon
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
- Links from Davids Segment
  - Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
  - 4-4.000 - COMMERCIAL LITIGATION
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

New Proposal for Dual-Eligibility Beneficiaries: Good Intentions or Cost Cutting?

Mon, 06 May 2019 14:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid.

More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. Could the CMS initiative suggest cost-cutting, administrative burden reductions, or true innovation? RACmonitor national correspondent J. Paul Spencer, a senior health consultant for DoctorsManagement, reports our lead story during this edition of the long-running Monitor Mondays live broadcast.

Other segments to appear on the broadcast include:

Court Report: Famed whistleblower attorney Mary Inman reports on the guilty verdict handed down Thursday by a federal grand jury in Boston that found Insys Therapeutics founder John Kapoor and four other executives guilty of criminal racketeering in bribing physicians to prescribe powerful opioids to patients who didn’t need them. Inman is a partner in the London office of Constantine Cannon.
2020 IPPS Proposed Rule: Social determinants of health (SdoH) are back in the news, since CMS is proposing to make homelessness a CC (complication and comorbidity) for the purposes of Inpatient Prospective Payment System (IPPS) coding. Does the CMS action signal that SDoH are a growing concern in the nation’s healthcare landscape? Continuing our reporting on this hot topic is nationally recognized SDoH authority and author Ellen Fink-Samnick.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will report on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Congressional Action on Surprise Balance Billing

Mon, 29 Apr 2019 12:00:00 -0400

News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing.

Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albright will also report on drug rebate discussions and how those discussions are being impacted by broader reform proposals such as Patient Protection and Affordable Care Act (PPACA) stabilization, outright repeal, and Medicare-for-all.

Other segments to appear on the broadcast include:

Monday Focus: Targeted Probe-and-Educate (TPE) audits are the Monday Focus, healthcare attorney Knicole Emanuel returns to the broadcast to report on what is believed to draconian efforts by TPE auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
IPPS Proposed Rule: Reporting on the release of the CMS proposed 2020 Inpatient Prospective Payment System (IPPS) rule for acute-care hospitals will be ICD10monitor contributing editor Laurie Johnson, a senior healthcare consultant with Revenue Cycle Solutions. See Laurie's Handout here.
FY 2020 Proposed Rule Tables
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics, including confusion surrounding the former functional G codes once used for Functional Limitation Reporting (FLR). Beckley also conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

ECAPE: Revealing the New Backlog Buster at OMHA

Mon, 22 Apr 2019 12:00:00 -0400

New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA.

Other segments to appear on the broadcast include:

Monday Focus: Healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will provide context and perspective to the ECAPE system at the OMHA.
IFF Report: One of the nation’s foremost authorities on inpatient rehabilitation (IRF) Angela Phillips will report on the proposed 2020 Inpatient Prospective Payment System (IPPS) for IRF that CMS posted on Wednesday.
The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on compliance issues associated with robotic surgery.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and conducts the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Is Disallowing an Appeals Process for a Decrease in Medicare Payments Unconstitutional?

Mon, 15 Apr 2019 13:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) recently announced that 800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row (the HAC Reduction Program has only been in existence for five years).

The Code of Federal Regulations does not allow a hospital to appeal the determination of poor results in this program, whereas if you are penalized by a Recovery Audit Contractor (RAC) or a Zone Program Integrity Contractor (ZPIC), you do have the right to appeal. With courts now finding that Medicare reimbursements are a property right, is 42 CFR 412.172 unconstitutional because it disallows an appeals process for a decrease in Medicare payments?

Reporting this latest development during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.

Other segments to appear on the broadcast include:

Monday Focus: The American Hospital Association (AHA) and the National Quality Forum have released a guide to help hospitals and health systems deliver tele-behavioral health services to improve patient outcomes and enhance access to behavioral healthcare. An estimated 44 million Americans have a behavioral health disorder. Reporting this developing story is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States in partnership with hospitals and health systems.
Big Pharma Lawsuits: Three pharmaceutical companies – Jazz Pharmaceuticals plc, Lundbeck LLC, and Alexion Pharmaceuticals, Inc. – have agreed to pay a total of $122.6 million to resolve allegations that they violated the False Claims Act by paying kickbacks to Medicare and Civilian Health and Medical Program (ChampVA) patients through purportedly independent charitable foundations. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story.
The IRF Countdown Continues: The Inpatient Rehabilitation Facility (IRF) countdown to Oct. 1, 2019 will end with the change to use quality indicators for case-mix group (CMG) for payment calculation. Reporting this story is one of the nation’s foremost IRF authorities, Angela Phillips, president of Images & Associates and longtime RACmonitor editorial board member and Monitor Mondays panelist.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Observation and Outpatient Status: Heading for Another Court Fight

Mon, 08 Apr 2019 00:00:00 -0400

The use and apparent abuse of observation and outpatient status are expected to have its day in court – again.

That’s because a federal judge has denied the government’s bid to put a stop to a landmark class-action lawsuit centering on patient status, paving the way for a trial expected to begin later this year. As reported by RACmonitor, in the court case Alexander v. Azar, the plaintiffs allege they were forced to pay up to $30,000 apiece for skilled nursing facility (SNF) care after being designated outpatients in observation status rather than inpatients, according to a press release on the matter by the Center for Medicare Advocacy (CMA).

Reporting on this important story during this edition of Monitor Mondays will be Judith A. Stein, the founder of CMA. She has extensive experience with Medicare advocacy projects, representing Medicare beneficiaries, producing educational materials, teaching, and consulting. She has been lead or co-counsel in numerous federal class-action and individual cases challenging improper Medicare policies and denials.

Other segments to appear on the broadcast include:

Monday Focus: The Medicare Home Health Review Choice Demonstration is expected to start in Illinois on June 1. The president and CEO for the National Association of Home Care and Hospice, William Dombi, reports on this latest news, which was announced on Wednesday.
Social Determinants of Health: A nationally recognized authority on the social determinants of health (SdoH), Ellen Fink-Samnick, returns to Monitor Mondays to report on the American Medical Association (AMA) and UnitedHealthcare agreeing to work together to support creating 23 new ICD-10 codes to report SDoH needs.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

CMS and Prescription Drug Prices, Part II: 340B State of the Union

Mon, 01 Apr 2019 00:00:00 -0400

In the final installment of a two-part series on prescription drug prices, during this edition of Monitor Mondays we will report on the latest initiative on a new “war on drugs” – the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered under the 340B federal drug program. Reporting on this development will be Maureen Testoni, Esq., president and CEO for 340B Health.

Other segments to appear on the broadcast include:

Monday Focus: J. Paul Spencer, senior healthcare consultant for DoctorsManagement and a RACmonitor national correspondent, reports on the latest update to the American Medical Association’s (AMA’s) 2021 evaluation and management (E&M) changes. https://www.racmonitor.com/an-overview-of-ama-s-e-m-revisions-for-2021/
Whistleblower Report: MedStar Health of Maryland has agreed to pay the government 35-million dollars to resolve allegations of under the False Claims Act that it paid kickbacks to a cardiology group. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and conducts the Monitor Mondays Listener Survey. Click to view SNF Prospective Payment PDF
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Howard A. Stein, DO, associate director of medical affairs for Centrastate Medical Center, makes his Monday rounds in the absence of Ronald Hirsch, MD.

CMS and Prescription Drug Prices, Part I: 2019 Drug Spending Dashboards

Mon, 25 Mar 2019 00:00:00 -0400

In the first portion of a two-part series on prescription drug prices, during this edition of Monitor Mondays we report on the Centers for Medicare & Medicaid Services (CMS) Drug Spending Dashboards with data for 2017.

First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousands of more drugs across Medicare Parts B and D and Medicaid. Reporting Part I of the series will be Timothy Powell, a regulatory expert and a RACmonitor national correspondent.

During Part II, scheduled for April 1, Maureen Testoni, president and CEO for 340B Health, will report on the state of the union of the drug discount program.

Other segments to appear on the broadcast include:

The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on the use of artificial intelligence (AI) to detect fraud in social health insurance programs.
CHS Whistleblower Lawsuit: Two former Community Health Systems (CHS) employees have alleged that CHS submitted hundreds of millions of dollars in false claims to the U.S. Department of Health and Human Services (HHS) for federal incentive payments under the CMS interoperability program for electronic health records. The whistleblowers allege that CHS received more than $450 million in incentive payments between 2012 and 2015. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will conduct the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Single-Payer Healthcare for New Yorkers: An Option on the Table

Mon, 18 Mar 2019 00:00:00 -0400

Could the Empire State be among the first to introduce a single-payer healthcare system?

The latest news coming from Albany would seem to indicate that; now that both state legislative branches are under control of the Democrats, such an option is likely viable. Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no access to healthcare.

Reporting our lead story during this episode of Monitor Mondays will be Dennis Jones, a New Yorker and the administrator of patient financial services at Montefiore Nyack Hospital in Nyack, N.Y.

Other segments to appear on the broadcast include:

Monday Focus: Revised E&M Codes: As expected, the American Medical Association’s (AMA’s) CPT® editorial board last month approved major changes to documentation and code selection guidelines for evaluation and management (E&M) codes. The changes were announced last week and are expected to become effective in 2021. Reporting this developing story is Shannon DeConda, founder and president of the National Alliance of Medical Coding Specialists—NAMAS
Whistleblower Report: Walgreens is facing a whistleblower’s False Claims Act challenge. The lawsuit alleges that pharmacies that the giant retail purchased in 2012 overcharged Medicaid for generic drugs by steeply discounting them to cash-paying customers. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, has the latest news on this major story.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
- Extrapolation Changes: Part II: The Centers for Medicare & Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, continues reporting on the changes and what they mean to providers.

Removing the Surprise from ED Billing

Mon, 11 Mar 2019 00:00:00 -0400

Pick up any healthcare news feed or relevant state or federal initiative, and no doubt you will see the "surprise billing" issue headlining. The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as "non-emergent."

Prudent acts among patients are ignored, common sense is discarded, and ethical conduct is cast aside in order to insist that patients pay astronomical bills for services that truly constitute emergency care.

These battles can take years. One such case will be discussed during this edition of Monitor Mondays; reporting our lead story will be Holly Louie, herself once an emergency department nurse.

Other segments to appear on the broadcast include:

Monday Focus: Bogus Charity Write-offs: The Patient Protection and Affordable Care Act (PPACA) created a new provision in Section 501 of the Internal Revenue Code that applies to facilities licensed as hospitals under state law, with new requirements for uncompensated care. The law also imposed new reporting requirements on hospitals. Running afoul of this issue could be a significant compliance violation, as you’ll learn when Timothy Powell reports on what many experts believe could be a major compliance bust.
United Behavioral Health Lawsuit: On Tuesday, a federal court in California found that United Behavioral Health (UBH) denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral healthcare. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, will have the latest news on this major story.
Extrapolation Changes: The Centers for Medicare & Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, reports on the changes and what they mean to providers
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Challenging the Ambiguity of an Agency’s Regulations

Mon, 04 Mar 2019 00:00:00 -0500

The preponderance of ambiguously worded regulations from federal agencies – think the Centers for Medicare & Medicaid Services (CMS) – will be at the center of a major legal challenge coming March 26 to the nation’s highest court, and you’ll hear the details here during this edition of Monitor Mondays.

That’s when Jennifer Gustafson will report our lead story, focusing on the U.S. Supreme Court (SCOTUS) taking up the case of Kisor vs. Wilkie (U.S. Marine James Kisor vs. the U.S. Department of Veterans Affairs).

The dispute is over denied Veterans Affairs (VA) benefits. In 1997, SCOTUS ruled that generally, federal courts are required to accept an administrative agency’s interpretation of its own ambiguous relations; this rule today is known as Auer deference.

Gustafson is a founding shareholder with The Health Law Partners, representing hospitals, health systems, hospices, home health agencies, physicians, and other healthcare providers and suppliers in an array of legal matters.

Other segments on the broadcast include:

Monday Focus: LTACH vs. Managed Care: Limiting access of Medicare patients to long-term acute care (LTAC) facilities by health insurance companies; reported on by Marvin Mitchell, the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles.
Prime Healthcare: Prime Healthcare Services will pay $65 million to settle a federal whistleblower lawsuit that accused the California hospital chain of Medicare fraud. Famed whistleblower attorney Mary Inman, has the latest news on this major story.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, maks his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also be following up on his segment last Monday on how to bill for inpatient services when there is no admission order.

Forensic Audits: Spurious or Genuine? Part II

Mon, 25 Feb 2019 00:00:00 -0500

Reaction to the reporting here on forensic audits continues to reverberate. During last week's Monitor Mondays broadcast, Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc., reported on her experience and efforts to appeal what she describes as "spurious" denials. As reported last Monday, these denials are for commonly billed services and items such as IV solutions, supplies, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc.

Michael Lewis, president of Financial Review Services of Houston, Tex. continues our reporting on this topic during this episode.

The episode rundown also includes:

Monday Focus: Analytics: Apropos of the lead story on forensic audits, senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, returns to the broadcast to report on the use of analytics to determine outliers.
The Roche Report: RACmonitor investigative reporter and New York attorney Edward Roche returns to the broadcast with another one of his intriguing reports on an under-reported healthcare issue.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch also reports on how to bill for inpatient services when there is no admission order.

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Forensic Audits: Spurious or Genuine?

Mon, 18 Feb 2019 00:00:00 -0500

Many hospitals are seeing increasing numbers of significant payment reductions that are the result of so-called “forensic” or other reviews conducted by third-party auditors. These are done on outlier claims, particularly for Medicaid HMO claims, as well as commercial and even Medicare Advantage claims.

The denials are for commonly billed services and items such as supplies, IV solutions, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc. The rationale given for the denials is that the charges are “unbundled” and should be included in a room rate or a procedure charge, or labeled “routine,” and thus not separately billable or payable.

Appeals are reported to be very time-consuming, with no guarantees of success. Reporting our lead story during this edition of Monitor Mondays will be Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc. Gilliland reports on her experience and efforts to appeal what she describes as “spurious” denials.

The broadcast rundown also will include:

Monday Focus: Readmissions: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for excessive readmissions that are often the result of a poor discharge process and medical decision-making. Reporting on readmissions will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital in New York.
Providence Lawsuit: Nationally recognized whistleblower attorney Mary A. Inman, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses.
Monday Focus: TPE Audits. Two different Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs), two different audits, both for the same issue: knee orthotics. Reporting on this topic will be Leann Wilhelm, a compliance officer for Kinex, a multi-state DME company located in Milwaukee, Wisc.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Is 340B at Risk?

Mon, 11 Feb 2019 00:00:00 -0500

“It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place," President Donald Trump told members of Congress during his State of the Union address on Wednesday. "This is wrong, unfair, and together we will stop it. We will stop it fast," the President warned. During his address, the President also pledged to end the HIV epidemic in the nation.

Both issues will be discussed during this edition of Monitor Mondays, when Maureen Testoni, president and CEO for 340B Health, returns to the broadcast. Testoni is considered to be one of the nation’s leading experts on the 340B drug pricing program and was recently was recognized as one of the “100 Most Influential People in Healthcare” by Modern Healthcare.

The broadcast rundown also will include:

Medicare Advantage: Are managed care beneficiaries being deprived of an important benefit? Enrolling in MA plans, beneficiaries expect to receive the same benefits as in traditional Medicare. But as providers move toward DRG payments, MA plans decline authorization for long-term acute care (LTAC) for patients with prolonged respiratory requirements and those with prolonged needs. MA plans feel that these patients should remain in the hospital under the original DRG payment. Reporting on this developing story is Howard Stein, MD, associate director of medical affairs and physician advisor in care management at CentraState Medical Center in Freehold, N.J.
Anthem Lawsuit: Nationally renowned whistleblower attorney Mary Inman reports on the recent class action lawsuit filed against Anthem Health.
Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on a scientific breakthrough in DNA sequencing.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Monday Rounds: Juliet Ugarte Hopkins, MD, Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin makes her Monday rounds while substituting for Dr. Ronald Hirsch.

Out of Town by Sundown: “Must Be Done by End of Business Day.” Payer-Provider Pressure

Mon, 04 Feb 2019 00:00:00 -0500

Are you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied?

Are you being told you cannot have a peer-to-peer session because your request was considered late?

Are you hearing that you must have everything — “pre-denial” or “pre-auth” — done within 72 hours of notification, only they typically wait until they only have three hours left?

During this edition of Monitor Mondays, listen and learn what Val Kraus and his team at one major Midwest health system are doing to reduce the impact of these scenarios.

The broadcast rundown also will include:

Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on what he says is the death of statistical extrapolation of Medicare audits by way of qui tam demands.
Opioid Crisis: The Purdue Lawsuit: Nationally renowned whistleblower attorney Mary Inman, featured in The New Yorker, returns to the broadcast to report on the major opioid lawsuit involving Purdue Pharma. The lawsuit is part of a national effort to force pharmaceutical companies to pay, in part, for the damage inflicted as a result of opioid healthcare crisis.
Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on Medicare Advantage and other problematic issues facing providers.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

TKA 2.0: CMS Updates Total Knee Arthroplasty, Again

Mon, 28 Jan 2019 00:00:00 -0500

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an updated memo on the subject on Thursday.

The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story during the next edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare.

The broadcast rundown also will include:

Monday Focus Report: Blockchain: Distributed ledger systems (DLS), also known as blockchain, will be the Monday Focus when RACmonitor investigative reporter and New York attorney Edward Roche will report on new healthcare technologies we can expect to see in 2019.
War on Drugs: The U.S. Department of Justice announced this week that Walgreens Boots Alliance agreed to pay $269.2 million to settle two healthcare fraud lawsuits alleging that Walgreens overbilled the government. In a related matter, United HealthCare Services filed a federal lawsuit last week against more than 40 drug companies, alleging they violated federal and state antitrust laws. Whistleblower attorney Mary Inman will report on both lawsuits.
Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment “Risky Business,” in which he reports on problematic issues facing providers.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

Sepsis-3: Not in New York

Mon, 21 Jan 2019 00:00:00 -0500

On Tuesday, the Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2.

Dennis Jones, the administrator of patient financial services for Montefiore Nyack hospital, was there Tuesday when HANY made the announcement during its regularly scheduled managed care advisory group meeting. Jones, who was among the earliest correspondents to join Monitor Mondays in 2010, will return to the broadcast this coming Monday and report on this newly developing story. Also reporting on Sepsis-3 will be Denise Wilson, vice president of Intersect Healthcare + AppealMasters.

The broadcast rundown also will include:

False Claims Act: Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report on Intermountain taking its challenge of False Claims Act (FCA) to the Supreme Court.
The Audit Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, will report on the latest activities by auditors, including the Recovery Audit Contractors (RACs).
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

2019: Look Out, Look Ahead

Mon, 14 Jan 2019 00:00:00 -0500

2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. And RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade.

Monitor Monday host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2019 during the next edition of the weekly Internet broadcast:

Duane Abbey, PhD; Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Frank Cohen, MPA; William Dombi, Esq.; Knicole Emanuel, Esq.; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; Angela Phillips, PT; Lauren Riplinger, JD; Edward M. Roche, PhD, JD; and Andrew Wachler, Esq.

All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

The Dilemma of Sepsis Reporting

Mon, 10 Dec 2018 12:00:00 -0500

Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare & Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3.

Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of care management at Trinity Health, will share how her system approaches the dilemma of sepsis.

The broadcast rundown also will include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
The Audit Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, returns to report on a new audit by Brown University that reveals the targeting by Medicare Advantage auditors of certain skilled nursing facilities (SNFs).
Monday Focus: Rural Health Report: Data from the Centers for Disease Control and Prevention (CDC) reveal another decline in life expectancy. Suicide and drug overdoses continue to be major factors, and suicide rates in rural counties are reported to be nearly double that of urban counties for 2017. Reporting on the state of healthcare in rural America is Leslie Marsh, chief executive officer at Lexington Regional Health Center in Lexington, Neb.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility
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Hirsch’s Heroes: Dr. Hirsch will also profile his 2018 “Hirsch’s Heroes” during his popular annual holiday segment.

Dismissal Expected in Providence Health FCA Lawsuit

Mon, 03 Dec 2018 13:00:00 -0500

During this edition of Monitor Mondays, nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States declined to intervene in the case, and the allegations are likely to be dropped on Jan. 14, 2019.

The broadcast rundown also will include:

Monday Focus: Lawmakers in Michigan have approved permanent medical marijuana licensing rules, including a provision to allow dispensaries to deliver the drug to cardholders' homes. RACmonitor investigative reporter and New York attorney Edward Roche will report on the adoption of cannabis therapy in Medicare.
The Audit Report: Becky Charlton, RN, denials/appeals coordinator at Blessing Hospital in Quincy, Ill., reports on her hospital’s plans to appeal a denied claim for an inpatient stay by KEPRO,a Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). The episode generated national attention when it was reported that KEPRO revealed the existence of a secret CMS memo.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
100 Percent Error Rates, Every time: Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on why he’s suspicious when auditors that review claims report 100 percent error rates, all the time.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Medicare Advantage Claim Denials: More Egregious, or More Awareness?

Mon, 26 Nov 2018 15:00:00 -0500

Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem?

Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the American College of Physician Advisors. Dr. Baker has been working with the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in writing statements noting that these plans have to follow original Medicare regulations for non-contracted facilities.

The broadcast rundown also will include:

Medicare Advantage Report: A central concern about the capitated payment model used by Medicare Advantage Organizations (MAOs) is the financial incentive for them to inappropriately deny access to services and reimbursements for services rendered in order to increase their profits, according to Knicole Emanuel, partner at the Potomac Law Group, who reports on this developing story.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron answers listeners’ questions from previous broadcasts on subjects that could be potentially troublesome.
“Hello, Are You There?” Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on problems now being created because a Quality Integrity Contractor (QIC) failed to respond to his appeal issues.
When Minutes Count: Phones lit up and social media seemed to explode last week when CMS announced it might not allow minutes to count when therapy services are provided by students. The exclusive story was reported on RACmonitor by nationally renowned inpatient rehabilitation facility (IRF) expert Angela Phillips, the president and CEO of Image and Associates. Phillips reports on the details behind the news that is rocking IRF providers’ worlds.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Court Orders HHS to Clear Medicare Appeals Backlog

Mon, 12 Nov 2018 13:00:00 -0500

U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates.

In other news, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Medicare Home Health final rule. Reporting on this major story will be William Dombi, president of the National Association for Home Care and Hospice.

The broadcast rundown also will include:

Death by Cyber, Part III: RACmonitor investigative reporter and New York attorney Edward Roche will report on how healthcare IT adds to the cost of healthcare, but without offering benefits.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

2019 MPFS and OPPS Final Rules: Where Are We Today

Mon, 05 Nov 2018 00:00:00 -0500

Long awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to the regulations governing evaluation and management (E&M) services.

For an in-depth analysis of both the MPFS and the OPPS newly released final rules, Monitor Monday has brought together a pair of industry experts for this edition of the broadcast: Duane Abbey, president of Abbey and Abbey Consultants, and Sean M. Weiss, partner and vice president of compliance for DoctorsManagement.

The broadcast rundown also will include:

OIG Report: In a recent study, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reported that Medicare Advantage Organizations (MAOs) overturned 75 percent of their own prior authorization and claim denials from 2014 to 2016. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, provides details on this latest developments.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.
TPE: Targeted probe-and-educate (TPE) audits are taking place in a variety of settings, from physical therapy providers to skilled nursing facilities (SNFs), including acute-care facilities. Reporting on TPE audits is Cindy Griffith, director of compliance and audits for ATI Physical Therapy.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Provider-Based Clinics: Major Changes Coming Soon

Mon, 29 Oct 2018 00:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November. The proposed changes are expected to impact compliance and reimbursement. Reporting this developing story during this edition of Monitor Mondays is author, educator, and consultant Duane Abbey, who will discuss how the proposed changes are likely to impact Medicare providers.

The broadcast rundown also will include:

False Claims Act: Famed whistleblower attorney Mary A. Inman, a partner at Constantine Cannon’s London office, reports that DaVita Medical Group has agreed to pay $270 million to CMS to settle False Claim Act allegations over questionable billing practices that led Medicare Advantage plans to receive inflated Medicare Part C risk adjustment payments.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Legislative Update: In California, there’s a bill on the November ballot (SB 1152) that would amend an existing law by establishing a uniform discharge planning process that takes into account the unique needs of homeless patients. Reporting on this proposition is Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital, east of Los Angeles.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

CMS Proposes Changes to Medicare Shared Savings Program: Probing the Impact on Providers

Mon, 22 Oct 2018 00:00:00 -0400

The Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program. Reporting this developing story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, who will discuss how the proposed changes are likely to impact Medicare providers.
The broadcast rundown also will include:

TPE: Targeted Probe and Educate Audits continue to generate confusion and concern. Returning to report on this developing story is healthcare attorney Andrew Wachler who has a follow-up to his reporting last Monday on Monitor Monday.
Death by Cyber, Part II: RACmonitor investigative reporter and New York attorney Edward Roche reports on how healthcare IT enables pharmacy benefit managers to keep drug prices high.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Targeted Probe-and-Educate Audits: Three Strikes and You’re Out

Mon, 15 Oct 2018 00:00:00 -0400

Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to a Recovery Audit Contractor (RAC), suspension of Medicare payments, or even revocation of Medicare billing privileges.

Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. Wachler offers some practical tips and strategic approaches for responding to TPE audits to reduce claim denials.

The broadcast rundown also will include:

Developing Story: PIM Change: CMS is proposing major changes to the Program Integrity Manual (PIM) – changes that will take effect Jan. 1, 2019. Senior healthcare analyst Frank Cohen, director of analytics and business intelligence for DoctorsManagement, reports on the changes involving sampling and extrapolation.
Death by Cyber: RACmonitor investigative reporter and New York attorney Edward Roche suffered a life-threatening medical emergency while in Barcelona, Spain. Roche reports on the one mainstay of America’s hospitals that was missing while he was hospitalized and ultimately experienced a complete recovery.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest with TPE audits.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

UnitedHealthcare Puts Sepsis in the Crosshairs

Mon, 08 Oct 2018 00:00:00 -0400

UnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present.

If reviewers find no SOFA score in the medical record, that could spell trouble – audit trouble. Reporting on this topic during this edition of Monitor Mondays is Edward Hu, MD, executive director of Inpatient Physician Advisor Services for the University of North Carolina Health Care System and president of the American College of Physician Advisors.

The broadcast rundown also will include:

The RAC Report: Healthcare attorney Knicole Emanuel reports on a flurry of new cases in which judges are ordering the government to refrain from recouping alleged overpayments until a hearing has been held. Immediate recoupments, currently allowable by law, fundamentally violate our country’s concept of due process.

Medicare Advantage Report: A recent investigation by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that Medicare Advantage plans overturned 75 percent of their denials. Timothy Powell, Monitor Monday national correspondent, reports on this developing story.

Rural Health Report: There has been a spike in the closure of rural hospitals, according to the Government Accountability Office (GAO). In a recent report, the GAO says that a total of 64 rural hospitals closed between 2013 and 2017. In the face of that bad news, Leslie Marsh, the chief executive officer for Lexington Regional Health Center in Lexington, Neb., reports on the positive economic impact her facility is having on the community.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monitor with us™

CMS Proposes to Implement Home Health Pre-Claim Review Demonstration

Mon, 01 Oct 2018 00:00:00 -0400

Home health providers are now on alert following an announcement on Wednesday that the Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas.

In its announcement, CMS issued a notice for a 30-day public comment period. Reporting this developing story during this edition of Monitor Mondays will be William A. Dombi, president of the National Association for Home Care and Hospice.

The broadcast rundown also will include:

Monday Focus: The newest compliance issue to gain national attention involves the T codes. As of Oct. 1, providers are required to document clients who might be at risk of sex and labor exploitation. Reporting on this story is nationally recognized authority on the social determinants of health (SdoH), Ellen Fink-Samnick.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Payment Report: Are small, independent providers being forced by CMS to increase their size so that there is enough activity to have the averaged national payments break even, or be profitable? Author, educator, and consultant Duane Abbey, president of Abbey and Abbey Consultants, Inc., reports on this timely issue.

The Hospice Report: Are referrals to hospice frequently the result of misunderstandings of the purpose of hospice? And why the rush to hospice if death is imminent? Marvin D. Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in California, reports on this critically important subject.

CMS Proposed Rule Intended to Alleviate Regulatory Burdens: Will it Work?

Mon, 24 Sep 2018 00:00:00 -0400

As expected, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.

The broadcast rundown also will include:

Monday Focus: Giant healthcare insurer UnitedHealth is back in the news, this time for being named in a lawsuit involving Medicare Advantage. Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports the details of this developing story.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Florence Watch: Marvin D. Mitchell, director of case management and social services at San Gorgonio Memorial Hospital, reports on the long-term consequences of Florence and its impact on Medicare and Medicaid beneficiaries.

Monitor with us™

Compliance During Adversity: Hurricane Florence

Mon, 17 Sep 2018 00:00:00 -0400

As bands of rain and wind from Hurricane Florence are lashing North Carolina, hospitals, health systems, and physician practices are preparing for what is being called the “storm of a lifetime.” Earlier this week, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that Medicaid and Medicare beneficiaries have access to medical care despite the storm, according to a posting on the HHS website. HHS also said it has positioned about 230 medical personnel in North Carolina and Maryland to help communities that may need extra medical support. In addition, HHS reported that it is working to make more ambulances available to help evacuate hospitals and nursing homes.

During this edition of Monitor Mondays: Reporting live from Charlotte, North Carolina will be Sharon Easterling, CEO for Recovery Analytics, LLC. Also on the broadcast will be Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health and former emergency department and intensive care unit case manager.

The broadcast rundown also will include:

Monday Rounds: Daniel Zirkman, MD makes his monday rounds from his facility, CarolinaEast Health System in New Bern, North Carolina where he is the chief physician advisor.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Compliance Report: Regulatory expert Timothy Powell, CPA, RACmonitor national correspondent, reports on compliance issues surrounding hospital readmissions.

Monitor with us™

Last Chance to Take a Stand: Comment Period for Proposed E&M Changes Ends

Mon, 10 Sep 2018 00:00:00 -0400

Few proposals from the Centers for Medicare and Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E and M) reimbursement changes in the 2019 Medicare Physician Fee Schedule.

The outrage has been intense over the plan to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to established patient visit codes 99212-99215. Code 99211 would also be paid a lower rate. The level 1 codes don’t get the flat rate, because they don’t require the presence of a physician.

Making a final stand in opposition to the proposed changes during this edition of Monitor Mondays will Dr. Steven J. Meyerson, board-certified in internal medicine and geriatrics, and Holly Louie, past president of the Healthcare Business and Management Association.

The broadcast rundown also will include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monday Focus: Social Determinants of Health (SdoH) are coming into sharp focus, as Tropical Gordon impacted parts of the Central Gulf Coast this week. It brought with it memories of Hurricane Harvey and its impact that is still being experienced in Houston, especially among the poor, the unemployed, and the disenfranchised – those who are predisposed to SDoH. Reporting on the compliance issues surrounding SDoH will be nationally recognized topic authority Ellen Fink-Samnick.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Monitor with us™

Anatomy of an Alleged False Claims Act Violation: The Providence Health & Services Lawsuit

Mon, 27 Aug 2018 00:00:00 -0400

A False Claims Act lawsuit has been filed by Integra Med Analytics against Providence St. Joseph Health, seeking $188.1 million related to alleged upcoding of Medicare claims.

According to media reports, Integra made the discovery of allegedly unwarranted major complication and comorbidity secondary codes. In its investigation, Integra identified J.A. Thomas and Associates (JATA) as the clinical documentation improvement consultancy for Providence. The lawsuit alleges Providence and JATA were "pushing doctors to make unwarranted diagnoses" and "using leading queries to change doctors' original diagnoses."

Reporting our lead story during this edition of Monitor Mondays will be False Claims Act attorney Mary Inman, partner in the London law office of Constantine Cannon. Also on board reporting the data analytics associated with this developing story will be senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement.

The broadcast rundown also will include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monday Focus: Michael Salvatore, MD, FACP reports on the ancient practice of alchemy and how its modern-day equivalency is turning health into disease. Dr. Salvatore is the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron continues his reporting on the perennial question, “should I refund an overpayment?” He will pose the question as a listener quiz.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.
Monitor with us™

CMS, Are You Listening? Podiatrists React Negatively to Proposed E&M Changes

Mon, 20 Aug 2018 00:00:00 -0400

“Podiatrists should not be discriminated against any further. E&M (evaluation and management) requirements are the same as (those for) other providers, and we should be reimbursed justly,” one podiatrist recently wrote, expressing his opposition to the Centers for Medicare & Medicaid Services’ (CMS’s) proposed E&M reimbursement changes in the recently posted 2019 Medicare Physician Fee Schedule.

“If Medicare is going to change E&Ms to only two codes, then all specialists should be changed,” another opined. “All I have to ask is what about optometrists? Why aren't you focused on them as well?”

Reported by RACmonitor, the controversy centers on the proposal by CMS to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to established patient visit codes 99212-99215. Code 99211 would also be paid a lower rate. The level 1 codes don’t get the flat rate, because they don’t require the presence of a physician.

Reporting on this developing story on this edition of Monitor Mondays will be Jeffrey D. Lehrman, DPM, diplomate of the American Board of Foot and Ankle Surgery.

The broadcast rundown also will include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monday Focus: The proposed E&M changes are expected to impact providers’ bottom lines. But by how much? Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, has done the math and shares his analysis.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

False Claims Act Report: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on the $65 million settlement by Prime Healthcare to resolve allegations that its hospitals submitted false Medicare claims.

Medicare Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare compliance.

Monitor with us™

Controversy Continues to Swirl Around Proposed E&M Changes

Mon, 13 Aug 2018 00:00:00 -0400

The Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes in the recently posted 2019 Medicare Physician Fee Schedule continue to generate controversy. The controversy centers around the proposal by CMS to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to established patient visit codes 99212-99215. Code 99211 would also be paid a lower rate. The level 1 codes don’t get the flat rate, because they don’t require the presence of a physician.

Reporting this developing story during this edition of Monitor Mondays will be Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as president of coding and billing services and a partner at DoctorsManagement, LLC.

The broadcast rundown also will include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monday Focus: Lori O’Hara, the lead of the additional documentation request (ADR), appeals, and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, reports on the impact of the Inpatient Prospective Payment System (IPPS) final rule as it pertains to skilled nursing facilities.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
IRF Report: One of the nation’s most respected authorities on Inpatient Rehabilitation Facility (IRF) provider issues, Angela Phillips, president and chief executive officer for Images & Associates, reports on IRF provisions that will be impacted by the IPPS final rule.

Monitor with us™

2019 Medicare Physician Fee Schedule and the Outpatient Prospective Payment System: Analyzing the Impacts on Providers

Mon, 06 Aug 2018 00:00:00 -0400

The Medicare Physician Fee Schedule/resource-based relative value scale (MPFS/RBRVS) regulations were formally published in the Federal Register on July 27, 2018. The Outpatient Prospective Payment System/Ambulatory Payment Classifications (OPPS/APCs) was released two days prior. Both were reported by RACmonitor. Although you can expect the final changes to published in early November, for a contemporary analysis listen to Duane Abbey during this edition of Monitor Mondays. Duane Abbey is president of Abbey and Abbey Consulting, Inc., and is RACmonitor contributing editor and a frequent panelist on Monitor Mondays.

The broadcast rundown also will include:

Monday Focus: Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as president of coding and billing services and a partner at DoctorsManagement, LLC, reports on the reaction to the proposed overhaul of the E&M guidelines by CMS.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also present the Monitor Mondays Listener Survey.

Monitor with us™

Beware: Emerging New Payer Denial for COPD

Mon, 30 Jul 2018 00:00:00 -0400

There’s a new and disturbing payer denial—a situation that has caught the attention of the Brundage Group. An insurance company removed the diagnosis of COPD exacerbation because the treating physician chose not to treat using steroids. Could this denial be happening at your facility? Dr. Brett Hoggard, chief medical officer for the Brundage Group, reports on this new and disheartening denial technique.

The broadcast rundown also will include:

The RAC Report: RACmonitor Legislative Analyst Emily Evans, managing director of health policy for Washington, D.C.-based Hedgeye, reports on the latest developments of the Recovery Audit Contractors (RACs).

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, anchors the broadcast. Nancy will also report on all the latest hot topics.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also present the Monitor Mondays Listener Survey.

Monitor with us™

Court Ruling Creates Major Setback for 340B Drug Program

Mon, 23 Jul 2018 00:00:00 -0400

The 340B drug pricing program suffered a major setback Tuesday, when the U.S. Court of Appeals dismissed a key American Hospital Association (AHA) lawsuit to block $1.6 billion in cuts.

The three-judge panel ruled that the lower court had properly dismissed AHA's case because the association failed to fulfill the legal prerequisites to judicial review. Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner at the Potomac Law Group.

The broadcast rundown also will include:

False Claims Act Report: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on Health Quest. The system and some of its subsidiaries have agreed to pay more than $14.7 million to the federal government and an additional $895,427 to the state of New York to resolve False Claims Act allegations that they submitted claims to government payers for evaluation and management (E&M) services that were billed two levels higher than was supported by the medical record.

IRF Report: One of the nation’s leading Inpatient Rehabilitation Facility (IRF) authorities, Angela Phillips reports on the fact that IRFs that received a notice of non-compliance and believe the notice is in error have only until Aug. 7, 2018to submit a request for reconsideration.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey.

Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monitor with us™

Case Management in the ED: Getting Patient Status Right the First Time

Mon, 16 Jul 2018 00:00:00 -0400

Case managers being situated in the emergency department (ED) appears to be a trend that is gaining traction nationwide, as results indicate that such a move helps determine appropriate status while also identifying patients who are appropriate for placement into a skilled nursing facility (SNF) directly (instead of placing them into the hospital while searching for a facility).

We have two reports on this trending topic during this edition of Monitor Mondays. Leading our report is Juliet Ugarte Hopkins, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Hopkins will also report on structured interdisciplinary bedside rounds (SIBRs), an emerging practice that allows collaboration with the care team on a daily basis.

Providing a first-person perspective on the role of case managers as registered nurses in the ED will be Kathleen K. Borchard, an RN case manager at Waukesha Memorial Hospital, also in Wisconsin.

The broadcast rundown also will include:

RAC Report: Healthcare attorney Knicole Emanuel, a partner at the Potomac Law Group, has the latest news on the Recovery Audit Contractors (RACs).

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the 2019 Proposed Medicare Physician Fee Schedule’s impact on outpatient therapy.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, reports on the 2019 Proposed Medicare Physician Fee Schedule released by CMS on Thursday.

Monitor with us™

The Readmissions Quagmire: Medicaid Work Requirements Pose Audit Risks

Mon, 09 Jul 2018 00:00:00 -0400

The state of Kentucky has introduced Medicaid work requirements. And the trend seems to be proceeding fast and furiously in other states looking to cut health and behavioral health benefits of Medicaid enrollees, with officials saying the costs can’t be met otherwise. Kentucky eliminated vision and dental benefits to 500,000 Medicaid enrollees within 36 hours of the federal decision.

Imagine the impact to the readmissions quagmire if benefits continue to be cut for the most vulnerable and disenfranchised members of society, or those most impacted by the social determinants of health (SdoH).

These costs are already eye-raising: $1.7 trillion is being spent annually on 5 percent of the population. Readmission penalties are barely being managed across all hospitals, especially the safety net facilities.

What will the continued impact of forcing shifts in Medicaid benefits be for the patients who need them most? Reporting on this latest development during the next edition of Monitor Mondays is nationally recognized SDoH expert Ellen Fink-Samnick, author, consultant, and founder of EFS Supervision Strategies, LLC.

The broadcast rundown also will include:

Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on the largest-ever healthcare bust, involving more than $2 billion in fraudulent billings. According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Monitor with us™

Appeal Relief Has Arrived: OMHA Implements Expansion to Settlement Conference Facilitation

Mon, 25 Jun 2018 00:00:00 -0400

The Office of Medicare Hearings and Appeals (OMHA) has implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process. The process provides appellants and the Centers for Medicare & Medicaid Services (CMS) an opportunity to discuss a mutually agreeable resolution for claims appealed to the administrative law judge (ALJ) or Medicare Appeals Council (Council) levels of appeal.

Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Erin Diesel Roumayah with Wachler & Associates.

The broadcast rundown also will include:

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will report on all the latest hot topics and present the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, will continue to report on the vexing issue of Medicare Advantage.
Special Assignment: Author, educator, and consultant Duane Abbey, president of Abbey & Abbey Consultants, Inc., will report on the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.r, a senior healthcare consultant for DoctorsManagement, will continue to report on the vexing issue of Medicare Advantage.
Monday Rounds: Christopher Halleman, DO, physician advisor at the Brundage Group, will be making his Monday Rounds, substituting for Dr. Ronald Hirsch, who is on assignment.

Monitor with us™

Pain Points of Pain Management Services

Mon, 18 Jun 2018 00:00:00 -0400

The National Institutes of Health (NIH)is expected to receive an additional $500 million to spend annually on pain management and opioid use. On Tuesday, the agency published details as to how the infusion of additional money will be used as part of a program titled “Helping to End Addiction Long Term (HEAL)."

Earlier this week, the Centers for Medicare & Medicaid Services (CMS) approved facet joint injections for auditing, warning that auditors will review medical documentation to determine that services were medically reasonable and necessary.

Reporting on this latest development will be American Medical Association (AMA) author and consultant Deborah Grider. Grider will also preview her upcoming webcast on the coding and documentation of pain management injections to avoid audits and takebacks.

Other segments to be featured on the broadcast include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey.

Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, reports on another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Special Assignment:Senior healthcare analyst Frank Cohen will return to the broadcast to continue his reporting of alleged bias he is uncovering in extrapolation audits

Monitor with us™

340B Drug Discount Program: What Happens Next?

Mon, 11 Jun 2018 00:00:00 -0400

Not unexpected but widely feared among healthcare providers, regulations setting 340B ceiling prices and establishing civil monetary penalties for drug manufacturers that knowingly and intentionally exceed those limits were delayed for the fifth time, until 2019, by the Trump Administration in a final rule published on Tuesday, June 5 in the Federal Register.

As the dust settles, America’s rural hospitals are expected to be impacted the most by an apparent lack of government enforcement, as the savings they receive from their participation in the 340B program —savings that are intended to keep doors open and allow for the provision of care for low-income and rural patients—are crucial to their survival.

Reporting on this developing story during the next edition of Monitor Mondays will be Maureen Testoni, Interim President and Chief Executive Officer for 340B Health, a nonprofit organization of more than 1,300 hospitals and health systems participating in the federal 340B drug pricing program.

Other segments to be featured on the broadcast include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

Special Assignment: Senior healthcare analyst Frank Cohen will return to the broadcast to continue his reporting of alleged bias he is uncovering in extrapolation audits. Cohen is expected to report on how a Zone Program Integrity Contractor (ZPIC) turned a $4,000 overpayment into a $3 million overpayment using extrapolation.

Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, will have an update on the major whistleblower case that is pitting Aetna against CVS for price spreading—this at a time when the two entities are trying to merge.

Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, will report on another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, will continue to report on the vexing issue of Medicare Advantage.

Monitor with us™

Alleged Bias Found in Extrapolation Audits

Mon, 04 Jun 2018 00:00:00 -0400

“Literally billions of dollars a year are being extorted from healthcare providers due to a system of rules, regulations, and guidelines that are not outdated, but just plain wrong,” writes senior healthcare analyst Frank Cohen, director of analytics and business Intelligence for DoctorsManagement in the current edition of the RACmonitor e-News. Cohen joined the Monitor Mondays broadcast to make his case and suggest strategies for improving what he believes is a flawed system of medical record auditing.

Other segments to be featured on the broadcast include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

OMHA Report: Healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, reports on the long-awaited expansion to the Settlement Conference Facilitation (SCF) program. Details were released last week by the Office of Medicare Hearings and Appeals.

Audit Report: Monitor Mondays national correspondent Knicole Emanuel, Esq., partner at the Potomac Law Group, reports on the latest activities by healthcare auditors.

Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, reports another example of a potentially troublesome issue that could pose a risk to your facility.

Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monitor with us™

Total Knee Replacement: The Intersection of Functionality and Care Levels

Mon, 21 May 2018 00:00:00 -0400

The subject of total knee replacement (TKR) continues to reverberate. In this edition of Monitor Monday, Lori O’Hara, the lead of the ADR, appeals and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, will offer the perspective of a long-term care provider. Her position is that a TKR patient either needs medical oversight or they do not. The question of the proper environment, O’Hara answered by finding where the patient’s medical and functional presentation intersects the lowest level of safe care.

The broadcast rundown also will include:

E&M Services: Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS), reports on E&M levels four and five.
Monday Newsmakers: Tim Brundage, MD, medical director at the Brundage Group, reported live from the ACDIS convention taking place in San Antonio, Texas.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reported on all the latest hot topics and present the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, reported on another example of a potentially troublesome issue that could pose a risk to your facility
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.

Monitor with us.™

Latest News: Feds Delay 340B Enforcement Rules

Mon, 14 May 2018 00:00:00 -0400

The Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally issued by the outgoing Obama Administration in January 2017. It was formally published on Monday. National Correspondent Timothy Powell reported our lead story on this episode of Monitor Mondays on 340B.

The broadcast rundown also will include:

Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reported on a whistleblower case that is attracting unprecedented media coverage—the nurse who knew too much.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, reported on all the latest hot topics and present the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported on another example of a potentially troublesome issue that could pose a risk to your facility.
Medicare Advantage Report: Monitor Mondays National Correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continued to report on the vexing issue of Medicare Advantage.

Monitor with us.™

IPPS Proposed Rule: Major Changes for IRF Providers

Mon, 07 May 2018 00:00:00 -0400

The dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear to be experiencing relief not typically associated with other proposed rule changes. For them, the proposals from CMS for FY 2019 reflect some positive changes related to reductions in paperwork and, if finalized, they will provide some easing of the workload. One of the nation’s most respected authorities on IRF provider issues, Angela Phillips, president and chief executive officer for Images & Associates, reported on the proposed IRF provisions in the IPPS during this edition of Monitor Mondays.

The broadcast rundown also will include:

Monday Focus: RACmonitor Legislative Analyst Emily Evans, managing director of health policy for Washington, D.C.-based Hedgeye, reported on what she sees as major themes of the Trump administration’s rulemaking that has been reflected in the proposed rule, including administration burden reductions, price transparency, and meaningful use measures.
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, reported on all the latest hot topics and presented the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported another example of a potentially troublesome issue that could pose a risk to your facility.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continued to report on the vexing issue of Medicare Advantage.

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Level of Care Versus Level of Care Billed: An Emerging Audit Problem

Mon, 30 Apr 2018 00:00:00 -0400

The problem begins like a blip on the radar screen: a curious anomaly that gradually grows more menacing. That is what Andrew Hughes, MD, and Charles Locke, both at Johns Hopkins, are noticing: an uptick in denials related to level of care provided versus the level of care billed.

The majority of the denials arise when documentation indicates that a patient is "stable for downgrade" and a transfer has been initiated but not yet effectuated due to a lack of an available bed, reported Dr. Hughes, who was the special guest on this edition of Monitor Mondays.

Other segments to be featured on the broadcast include:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment.
Whistleblower Update: Mary A. Inman, partner at Constantine Cannon's law offices in London, reported on the Aetna lawsuit filed against CVS Caremark accusing the pharmacy benefit manager of the giant retail pharmacy operation of improperly reporting Medicare generic drug prices to the Centers for Medicare & Medicaid Services (CMS).
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported on another example of a potentially troublesome issue that could pose a risk to your facility.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.
Medicaid Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, returns to the broadcast with the final installment of her exclusive two-part reporting on a state-by-state review of states' Medicaid regulatory oversight.
Monday Focus: The Bipartisan Budget Act of 2018 contains a number of healthcare issues that have caught the attention of author, educator, and consultant Duane Abbey, who outlined them during the broadcast.

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Auditing Non-physician Practitioners

Mon, 23 Apr 2018 00:00:00 -0400

Could non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors? While physicians reportedly represent nearly a million targets for audits, add in another couple of hundred thousand nurse practitioners (NPs) and physician assistants (PAs) and target acquisition becomes that much richer. And in their minds, so do the auditors, according to Frank Cohen, director of analytics and business intelligence for DoctorsManagement, who reports on his latest findings during this episode.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Medicaid Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, returns to the broadcast with the final installment of her exclusive two-part reporting on a state-by-state review of states' Medicaid regulatory oversight.
Monday Focus: Former First Lady Barbara Bush died Tuesday at age 92 at her home in Houston, having decided to decline further medical treatment for health problems and instead to focus on "comfort care." Reporting on palliative care is Michael A. Salvatore, MD, physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. Salvatore is a member of the RACmonitor editorial board.

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Facebook: Healthcare’s Social Media Menace

Mon, 16 Apr 2018 00:00:00 -0400

Facebook CEO Mark Zuckerberg faced two days of grilling by Congress last week to address data misuse in the wake of revelations that millions of Facebook users had their private information given away to political consulting firm Cambridge Analytica in the run-up to the 2016 Presidential election.

Zuckerberg testified before Congress that about 87 million users had their Facebook data taken without their permission. Of those users, many were healthcare professionals who inadvertently allowed hackers and criminals the information they need to break into healthcare systems.

Reporting this developing story will be RACmonitor national correspondent and healthcare consultant Timothy Powell. Powell will describe how you can avoid getting your facility ensnarled in the phishing trap.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Medicaid Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, returns with the first part of her exclusive two-part reporting on a state-by-state of review of states' Medicaid regulatory oversight.
Medical Necessity: Senior healthcare consultant Kristi Pollard reports on best practices for coding medical necessity on outpatient claims. Pollard is a senior coding consultant at Haugen Consulting Group.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.

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AHA Ordered to Fix the Medicare Appeal Backlog

Mon, 09 Apr 2018 00:00:00 -0400

Judge James E. Boasberg of the United States District Court for the District of Columbia has ordered the American Hospital Association (AHA) to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the Administrative Law Judge (ALJ) level.

Reporting this developing story is healthcare attorney Andrew Wachler, Esq., managing partner at Wachler and Associates.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, report on all the latest hot topics and presents the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
Consumer Alert: New Medicare beneficiary identification cards are scheduled to be mailed from the Centers for Medicare & Medicaid Services (CMS) this month to beneficiaries. And with the new cards come new scams. Author, educator, and consultant Duane Abbey will report on the new cards and the expected scams on bilked seniors.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.

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Telemedicine: Significant Expansion, Followed by a Return to Normalcy

Mon, 02 Apr 2018 00:00:00 -0400

Telemedicine, considered to be an electronic lifeline for rural healthcare, is a rapidly growing sector of health care in the United States that has recently gone through a significant expansion.

Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac's report on Telemedicine, is attorney Dale C. Van Demark, a partner at McDermott Will & Emery in Washington, D.C.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
340B Update: Monitor Mondays national correspondent Timothy Powell, CPA, reports on the status of the controversial 340B drug program.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.

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How to Predict the Likelihood of an Audit

Mon, 26 Mar 2018 00:00:00 -0400

Diving deep into the datasphere, senior healthcare analyst Frank Cohen comes up for air in order to report on a new approach he and his team of data experts have developed to predict the likelihood of an audit. While he claims that his team is not yet predicting billing errors, he does report that many of the variables being used to do so can also be used to forecast audits. During this episode Cohen, director of analytics and business intelligence for DoctorsManagement, reports on his latest findings, which could help you and your facility ward off an audit.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
IRF Update: Angela Phillips, one of the nation's foremost authorities on inpatient rehabilitation facilities (IRFs), reports on all the buzz about Medicare's most recent clarifications to contracted auditors related to auditing therapy minutes for IRFs.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.

Monitor with us™

Anthem BlueCross BlueShield and UnitedHealthcare: New Worries for Patients and Providers

Mon, 19 Mar 2018 00:00:00 -0400

Patients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful of not having their visits covered. Former ED physician-turned healthcare consultant Erica Remer, herself an Ohioan, reports on this developing story.

Another headline grabbing story is the reported lawsuit filed by Envision Healthcare against UnitedHealthcare (UHC). Envision is using the giant insurer alleging the UHC "unilaterally" lowered payments of Envision's contracted physicians, according to Axios. Healthcare attorney Mary Inman, a partner at Constantine Cannon, reports on this developing story, calling in from the firm's London office.

Yet another story about UHC is reported by Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS). UHC, DeConda reports, is cracking down on emergency ED service codes of Level 4 and 5.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a developing story that some facilities are receiving CERT letters containing misleading information.

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Medicare and Medicaid RAC Audits: How Auditors Get It Wrong

Mon, 12 Mar 2018 00:00:00 -0400

RACmonitor was founded in 2008 to provide news and information for healthcare providers on the emergence of the government’s Recovery Audit Contractor (RAC) program. From a Centers for Medicare & Medicaid Services (CMS) demonstration in that year, and continuing to the national rollout in 2010 (coincidentally, the year of Monitor Mondays’ national debut), we have been reporting on activities not only of the RACs, but also the Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), and the Quality Improvement Organizations (QIOs).

But why, after nearly 10 years, do these auditors still tend to get auditing wrong? Providing insight into this issue during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns and reports on all the latest hot topics and the Monitor Mondays Listener Survey.
News Update: RACmonitor national correspondent Timothy Powell reports on the move by UnitedHealthCare to adjust or deny emergency department (ED) claims submitted with levels four and five evaluation and management (E&M) codes. RACmonitor broke that story with Dr. Hirsch in December of last year.
Auditing Report: Kristi Pollard, senior coding consultant at Haugen Consulting Group, reports on a top audit finding uncovered by her firm: discrepancies in secondary diagnosis assignment on outpatient claims.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron shares another example of a potentially troublesome issue that could pose a risk to your facility.

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Quelling the Confusion Over Modifier 25

Mon, 05 Mar 2018 00:00:00 -0500

"Anthem Blue Cross Blue Shield (BCBS) was set to implement a new processing edit with regard to the use of Modifier 25, effective March 1, 2018, but things didn't go as planned," reports Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS), as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. During this episode DeConda explains why Anthem is rescinding the new policy.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
IRF Update: Angela Phillips, one of the nation's foremost authorities on inpatient rehabilitation facilities (IRF), reports on Medicare guidelines for an "interrupted stay" in the IRF, and for how services should be billed for these patients.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron shares another example of a potentially troublesome issue that could pose a risk to your facility.
Whistleblowers: Nationally recognized whistleblower attorney Mary Inman will reports on current whistleblower cases from the London offices of her firm, Constantine Cannon.

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Time to Junk the Peer-to-Peer Process?

Mon, 26 Feb 2018 00:00:00 -0500

"The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians," reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. "These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient."

During this episode of Monitor Mondays Dr. Hopkins makes the case for abandoning your P2P process if the results are not satisfactory. Might the pressure of P2Ps even be contributing to some physicians considering opting out of Medicare? Duane Abbey, PhD, president of Abbey and Abbey Consultants, Inc., will review the complexities of compliance facing physicians and practitioners who might consider throwing in the towel.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey.
Hospice Report: Theresa Forster, BA, vice president for hospice policy and programs for the National Association of Home Care and Hospice, reports on changes to the CMS Hospice Compare program announced Thursday.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a recent memo from the U.S. Department of Justice offering good news for some providers.

Monitor with us™

Total Knee or Total Consternation?

Mon, 19 Feb 2018 00:00:00 -0500

Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility?

Mary Beth Pace, vice president of care management at Trinity Health and the special guest on this edition of Monitor Mondays, frames the conundrum as a hypothetical patient/caregiver conversation: "we are going to do major surgery on you, but we are not sure if we will keep you after surgery – and oh, by the way, there will be a copay and deductible either way, we don't know which one. But don't worry, it will be a good thing to have your knee in working order again." Tune in to the podcast as she reports on how TKRs are admitted at Trinity.

Also reporting on this timely subject is Jeffrey Pilger, MD, a board-certified lead physician advisor affiliated with St. Elizabeth Healthcare Edgewood in Edgewood, Ky.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey.
Office of Civil Rights Report: Rita Bowen, with MRO, is a nationally recognized healthcare privacy expert. Bowen reports on the latest initiatives by the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), including updates on the HIPAA Audit Program, patient access guidance, and resolution agreements.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron shares another example of a potentially troublesome issue that could pose a risk to your facility.
Prior Authorization: Betty Lengyel-Gomez with the Healthcare Administrative Technology Association (HATA) reports on research HATA has conducted to remove barriers to the adoption of prior authorization transactions. Lengyel-Gomez is the industry relations and regulatory compliance director for MedInformatix.

Monitor with us™

EMR and RAC Audits: Who Takes the Hit? Part II

Mon, 12 Feb 2018 00:00:00 -0500

Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor Mondays, when whistleblower attorney Mary Inman reports on an ongoing qui tam action under the federal False Claims Act through which a relator alleges that Bon Secours Health System, Inc. fraudulently billed Medicare and Medicaid millions of dollars. Inman also reports on other current whistleblower cases.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a recent memo from the U.S. Department of Justice offering good news for some providers.
340B Drug Update: RACmonitor national correspondent Timothy Powell, CPA, reportS on the latest developments regarding the 340B drug discount program.

Monitor with us™

EMR and RAC Audits: Who Takes the Hit?

Mon, 05 Feb 2018 00:00:00 -0500

On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records?

Many of these electronic records are self-populated. So, what happens if you undergo a Recovery Audit Contractor (RAC) audit and are accused of wrongdoing? Offering insight into this issue during the next edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, who will be the broadcast's special guest.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer will continue to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on a recent memo from the U.S. Department of Justice offering good news for some providers.
Cyber Report: RACmonitor investigative reporter and New York attorney Edward Roche will report on risks associated with Apple's iPhone's new medical records portal. Roche is the director of scientific intelligence for Barraclough NY LLC.

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HEDIS Reviews: How to Avoid Payer Abrasion

Mon, 29 Jan 2018 00:00:00 -0500

Healthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called Star Ratings, which are ultimately published on the Centers for Medicare & Medicaid Services (CMS) website. Explaining the rating systems as well as offering best practices to minimize payer abrasion during this episode of Monitor Mondays is special guest Greg Ford with MRO.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will file another report on the controversial total knee replacement (TKR) issues that continue to confound physicians and patients.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey.
Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer will respond to a listener who become ensnared in a Medicare Advantage issue. Spencer is a senior healthcare consultant for DoctorsManagement.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will return with another example of a potentially troublesome issue that could pose a risk to your facility.
Prickly Report: Implantable medical device reporting is the prickly subject for the Monitor Mondays Prickly Report. It’s a compliance issue that still confounds providers while at the same time continues to be a hot audit topic for Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing (CERT), and Medicare Administrative Contractors (MACs). Michael Calahan, vice president of hospital and physician compliance with HealthCare Consulting Solutions (HCS), will explain why this issue is low-hanging fruit for auditors.

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Medicare Advantage: What’s the Advantage?

Mon, 22 Jan 2018 00:00:00 -0500

“We have been slammed with Medicare Advantage DRG audits,” wrote Sandra from Indiana during last week’s Monitor Mondays broadcast. We asked RACmonitor national correspondent J. Paul Spencer with DoctorsManagement to investigate this issue for this week's episode. Will there be more of these audits? Do these represent low-hanging fruit for auditors? Stay tuned.

The episode rundown also includes:

Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will file another report on the controversial total knee replacement (TKR) issues that continues to confound physicians and patients.
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey.
Healthcare Cyber Report: RACmonitor investigative reporter and New York attorney Edward Roche will return to the broadcast to report shocking examples of cyberattacks on healthcare providers. Roche is the founder and director of scientific intelligence for Barraclough LLC New York.
Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will return after a long absence with another example of a potentially troublesome issue that could pose a risk to your facility.
OMHA Report: Prominent healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will report on the latest offering from the Office of Medicare Hearings and Appeals to expand its current Settlement Conference Facilitation (SCF) program.

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2018: Look Out, Look Ahead

Mon, 15 Jan 2018 00:00:00 -0500

Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2018 during this edition of the weekly internet broadcast:

Duane Abbey, PhD
Janelle Ali-Dinar, PhD
Nancy Beckley, MS, MBA, CHC
Frank Cohen, MPA
William Dombi, Esq.
Knicole Emanuel, Esq.
Ronald Hirsch, MD, FACP, CHCQM
Angela Phillips, PT
Timothy Powell, CPA
J. Paul Spencer, CPC, CPC-H
Andrew Wachler, Esq.

2018 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade. All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

Monitor with us.™