Monitor Mondays

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

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: Mond

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 bro

“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

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 Advi

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 D

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 th

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)

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 broadc

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 Monday

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.

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 insta

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. Othe

“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 Off

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, pre

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

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 administratio

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 imp

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 Busines

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 at