Monitor Mondays

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 li

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 broadca

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 t

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 als

“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 tradition

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 o

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 Walgreen

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 rep

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 au

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

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 inpati

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 increas

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 Mo

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 cla

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 Californ

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,

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 (P

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 co

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

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 Associat