Monitor Mondays

A recent federal court decision in New Jersey demonstrates the viability of a different kind of whistleblower – in this case, a privately defrauded party.The most common type of a whistleblower under the False Claims Act (FCA) tends to be a corporate insider who sees fraud committed against the government by their employer or a company they work with, and generally after many, many attempts at internal reporting, sues the company under the law and is eligible to share in the recovery.During the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner of Whistleblower Partners, LLC, will report on how this uncommon type of whistleblower has created a lesson worth learning for healthcare leaders.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest

Artificial intelligence (AI) is fast becoming a fixture in healthcare revenue cycle management (RCM), where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision.During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report on why keeping humans in the loop is the best strategy for preventing negative outcomes.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Juliet Ugarte Hopkins, MD, substituting for Dr. Ronald Hirsch, will be making her Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation.• Risky Business: Healthcare attorney David Glaser, shareholder

They’re looking for fraudsters, going on the prowl for bad actors, as revealed in the latest semi-annual report to Congress compiled by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In this latest report, the government watchdog identified more than $2.76 billion in expected recoveries and receivables.Providing analysis and context for the OIG report released June 3 during the next edition of Monitor Mondays will be James S. Kennedy, MD, a subject matter expert who will review highlights and offer suggestions for remaining compliant.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation

Most healthcare investigations by the U.S. Department of Justice (DOJ) result in settlements. Many times, the complete details of the settlements in underlying government cases are not fully disclosed. But sometimes, a provider ends up at trial. And when that happens, it often offers insights into what it takes to get hit with hefty fines – and possible prison time, if you lose the case.During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will review two recent convictions against individual physicians, and offer suggestion for avoiding big payouts and incarceration.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on curren

A deep dive into microbiology can reveal an up-close look at the cells that make up organs of the human body – and corresponding cancer treatments that leave no trace of damage.The science of medicine appears to be moving at the speed of light lately. But will new healthcare technologies be audit-proof? Monitoring these escalating changes and their impact on America’s delivery of healthcare services during the next live edition of Monitor Mondays will be RACmonitor investigative reporter Edward M. Roche.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Clarrisa Barnes, MD, President and CEO for the American College of Physician Advisors, is substituting for Ronald Hirsch to report on her Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.Risky

Two recent settlements to resolve allegations of violating the False Claims Act – both involving the virulent COVID-19 – are the latest in a series of actions that will be reported on during the next edition of Monitor Mondays by famed whistleblower Mary Inman, who also notes that her company, Whistleblower Partners, LLP, is poised to announce another major case pending the unsealing of court documents expected this week.Among the two cases, one involves the U.S. and California versus ReNew Health Group, LLC and two of the firm’s executives. The settlement alleges that the company knowingly submitted false Medicare Part A claims for nursing home residents. The other settlement involves Atlanta-based Insight Global LLC, which allegedly failed to implement adequate cybersecurity measures to protect personal health information of individuals involved in contact tracing efforts.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM,

The arms race is heating up.On one side there are healthcare providers, and on the opposing side, an army operated by the auditors. Who will be the winners and losers?Are you safe? And how do you protect your facility from claim denials and takebacks, especially when auditors are using artificial intelligence (AI)?RACmonitor investigative reporter Edward M. Roche will return to Monitor Mondays this coming Monday to report on the escalating AI arms race. Roche, who just completed an exclusive three-part series for RACmonitor on AI auditing, will also report on essential steps you and your colleagues can deploy in defense of such audits.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Adam Brenman, a senior government affairs liaiso

Do you have peer-to-peer (P2P) discussions?Are they useful? Are they valuable? And how do you know?Our own physician and attorney, Dr. John K. Hall, will offer his unique take on the value of P2P interactions and how you should measure it during his appearance as Guest Panelist on the next upcoming edition of Monitor Mondays.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Matthew Albright, a senior government affairs liaisons for Zelis, will report on current healthcare legislation.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Like seasoned harbor pilots navigating tugboats through natural and manmade hazards, physician advisors each day face the daunting task of guiding their hospitals through a labyrinth of Medicare rules and regulations.Reporting on those conditions during the next edition of Monitor Mondays will be the vice chair of the recently concluded national conference of the American College of Physician Advisors, Stephanie Van Zandt. In that role, Dr. Van Zandt had a front-row seat to the history-making conference that concluded Thursday in Coronado, Calif. Dr. Van Zandt is expected to report on the key Medicare policy issues that continue to define the role of physician advisors.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Folana Housto

Artificial Intelligence (AI) software is now in the “hype phase” of adoption.It promises to increase the efficiency of medical audits. But also, AI is being touted as being able to handle much more data, examine many more cases, and instantly make decisions regarding medical necessity or inadequate documentation.The number of audits can be doubled, tripled, quadrupled. Why take samples for review when AI can audit every single claim submitted? Providers can expect a deluge of demands for recoupment, all delivered with exquisite and compelling prose.But is AI as accurate or as thorough or efficient as promised? During the next live edition of Monitor Mondays, RACmonitor investigative reporter Edward M. Roche will review basic defense strategies that providers can deploy against such audits, and look into the future to uncover some of the problems on the horizon.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making

The recent $37 million settlement against Cigna regarding enhancing risk adjustment factor (RAF) scores —along with related litigation by the U.S. Department of Justice (DOJ)— highlight the aggressiveness of the federal government to crack down on entities for non-compliant billing practices.During the next live edition of Monitor Mondays, Dr. James Kennedy will unpack the challenges entities have with this hot billing compliance issue. Dr. Kennedy will also recommend an approach that attempts to clarify what facilities and physicians can do to mitigate their risks.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with hi

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit that accuses Martin’s Point Health Care, along with five other providers in other states, of defrauding the government of more than $300 million, pertaining to allegations that the providers inflated patients’ risk scores to obtain higher payments to which they were not entitled from the government’s military health plan.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Whistleblower Report: Famed whistleblower attorney Mary Inman, founder of Whistleblowers Partners, returns to Monitor Mondays with recent news of healthcare whistleblowers.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his t

Since its launch in January 2021, the Hospital Price Transparency Rule from the Centers for Medicare & Medicaid Services (CMS) has been a vexing issue for many of America’s hospitals. Despite enforcement efforts from CMS, implementation for many providers has been onerous – so much so that when the latest requirements were issued by CMS, one could imagine provider executives simply giving up, rationalizing that non-compliance was the cost of doing business.But now there’s a chance for your team to achieve a clear vision for implementing the arduous tasks of compliance. During the next live edition of Monitor Mondays, Jory Hatton, CEO for ClaraPrice, will outline a list of actionable items that need to be executed in order to be compliant, as he concludes this essential three-part series.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanue

Many of America’s hospitals continue to be challenged as it pertains to complying with the requirements from the Centers for Medicare & Medicaid Services (CMS) for implementing the agency’s rule on hospital price transparency. And that is why RACmonitor and Monitor Mondays are producing a three-part series, in collaboration with ClaraPrice, to help providers fix this vexing problem, including addressing the onerous requirement for hospitals to produce their own machine-readable files (MRFs).Specifically, CMS is requiring hospitals to display their standard charge information in a CMS template layout, following data specifications and a data dictionary.But there’s even more stringent requirements from CMS that providers also must address.During the next live edition of Monitor Mondays, Jory Hatton, ClaraPrice CEO, will continue with the second part of this essential series to help ease the pressure to comply.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald

America’s hospitals are currently facing a critical challenge: a flood of patients placed under observation, leading to lost revenue and operational disarray. Amid the confusion, questions arise. Even seasoned bedside physicians struggle with uncertainty in determining patient status upon admission.But fear not! There is hope in this chaotic landscape, unlocked by empowering the bedside physician to invoke the full potential of the Centers for Medicare & Medicaid Services (CMS) Two-Midnight Rule.During the next live edition of Monitor Mondays, Dr. Stephanie Van Zandt from BayCare Health System in Florida will report on an innovative four-part process meticulously crafted by her team. She will explain strategies aimed at empowering emergency department (ED) providers and admitting hospitalists through comprehensive education on patient status determination.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making

There was a time when everyone in healthcare compliance and revenue cycle management was scrambling to implement the Hospital Price Transparency Rule.Now, nearly four years later, it’s back.The Centers for Medicare & Medicaid Services (CMS) 2024 Final Rule for Price Transparency marks the biggest change to the rule requirements since it initially took effect in January of 2021.The new mandate introduces a three-phase approach that began in January and will continue with new requirements effective in July, with additional requirements starting in January 2025. New technical mandates will introduce new challenges for hospitals, potentially forcing facilities out of compliance and creating a need for outside expertise to dig up pricing information and generate new data formats.With the new mandates will also come increased numbers of CMS audits, warning letters, and non-compliance notices, as the federal government begins to automate the auditing process.During the next live edition of Monitor Mondays, Jory

What happens if the Supreme Court of the United States (SCOTUS) dismantles decades of government agency discretion? Recent cases at SCOTUS indicate that this could happen. But what would be the consequences?During the next live edition of the long-running Internet radio broadcast Monitor Mondays, RACmonitor’s own physician and attorney Dr. John K Hall will consider the ramifications of the demise of the so-called “Chevron Deference” currently enjoyed by federal agencies.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, wi

The implementation of generative artificial intelligence (AI) in the Electronic Health Record (EHR) is one of several hot-button issues to be explored during the next live edition of the Monitor Mondays, the long-running Internet broadcast produced by RACmonitor.Other high-level considerations to be reported include leveraging AI in regulatory compliance, creating physician notes from doctor-patient conversations, and how AI could bridge knowledge gaps.Reporting on these latest developments in healthcare technology will be senior healthcare consultant Sharon Easterling. Since 2012, Easterling has played a pivotal role in supporting companies as they integrate natural language processing (NLP) and machine learning into their coding and clinical documentation integrity (CDI) technology, utilizing algorithms. During the broadcast, her focus will be more sharply focused on advancing initiatives within healthcare AI and leveraging AI technology.Broadcast segments will also include these instantly recognizable feat

The Merit-based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments. So, what’s the score for your physicians? Do they know?During the next live edition of the long-running Monitor Mondays, Leigh Poland, vice president of coding services for AGS Health, will report on why it’s essential for all eligible clinicians to report their score to prevent a 9-percent downward adjustment for all Medicare Part B claims paid two years from the reporting year.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast wi

Auditors use the Comprehensive Error Rate Testing (CERT) study from the Centers for Medicare & Medicaid Services (CMS) as a way to target individual providers for potential recoupment. For example, if you get paid millions of dollars for some procedure codes or DRGs that have high error rates, it increases the likelihood that those specific codes and/or DRGs will be audited. Why? Because, statistically speaking, whatever the error rate reported by CERT is can help estimate the potential improper payments made to a given provider and/or organization.During the next live edition of the venerable Monitor Monday broadcast, senor healthcare analyst Frank Cohen will return to continue his series on CERT.Broadcast segments will include these instantly recognizable features:•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. •Risky B