Monitor Mondays

RACmonitor

Join Chuck Buck every Monday when he welcomes RACmonitor contributing editors and special guests for the latest regulatory audit news and information from CMS, OIG and OMHA. And gain valuable context and perspective that can only be found when you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: https://event.webcasts.com/starthere.jsp?ei=1235505&tp_key=eae2082467

Swimming Among Sharks in a Sea of Turmoil: 2022 Audit Landscape
Nov 21 2022
Swimming Among Sharks in a Sea of Turmoil: 2022 Audit Landscape
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.
Winds of Change in the South: No Jubilee with Cotiviti
Nov 14 2022
Winds of Change in the South: No Jubilee with Cotiviti
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
Nov 7 2022
2023 Medicare Physician Fee Schedule Final Rule: Telehealth Services Post-COVID-19
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.
Exclusive Report: Winds of Change Blowing for Medicare Advantage Plans
Oct 24 2022
Exclusive Report: Winds of Change Blowing for Medicare Advantage Plans
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
Oct 17 2022
The Tables Are Turning: OIG Sets Sights on Medicare Advantage DRG Validation Denials
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; andLegislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
Exclusive: Some Extrapolation Estimates Vacated
Oct 10 2022
Exclusive: Some Extrapolation Estimates Vacated
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
Oct 3 2022
False Claims Act: Biogen to Pay $900 Million: Whistleblower Gets $250 Million
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
Sep 26 2022
Beware: Enforcement of the Hospital Price Transparency Rule
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.
Medicare: The New Drug Price Negotiator
Sep 19 2022
Medicare: The New Drug Price Negotiator
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
Sep 12 2022
Medical Necessity: The Necessity of Defining the Dilemma
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.
Medicare Advantage: OIG Warns: Don’t Deny Payments
Aug 29 2022
Medicare Advantage: OIG Warns: Don’t Deny Payments
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
Aug 22 2022
Medicare Telehealth: The Perils of Fraud and Abuse
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.