Monitor Mondays

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:Crisi

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 attorn

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 Pract

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 partn

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 legislat

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

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:

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 repo

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 R

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

SPECIAL GUESTEdward Roche, JD, PhDDirector, Scientific Intelligence, Barraclough NY LLCALSO FEATURINGMatthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP;David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQRACmonitor 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: Ron

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 tradem

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

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 hos

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

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 segm

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

“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

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 affa

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