Monitor Mondays

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

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 editoria

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 a

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 broad

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

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 signifi

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. Em

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 Chi

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 Thursd

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 permanen

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 Can

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 con

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

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 o

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

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 Am

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 challengin

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 allegation

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 Communit

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 Shann