Monitor Mondays

The Government Accountability Office (GAO) is recommending expansion of the Medicaid Recovery Audit Contractors (RACs) program, to include auditing of payments made to managed care organizations (MCOs), according to a GAO report released in June.Launched in 2011 as a consequence of the Patient Protection and Affordable Care Act (PPACA) by the Centers for Medicare & Medicaid Services (CMS), the Medicaid RACs were purported to be aggressive in their recouping of alleged Medicare Fee-for-Service (FFS) overpayments. They could now be poised to expand into the rapidly growing MCO plans.  During the next live edition of Monitor Mondays, Dennis R. Jones, senior director of revenue cycle at Jefferson Health, will report on this developing story.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the lat

There is a buzz swirling within the healthcare auditing community. And thanks to RACmonitor investigative reporter Edward M. Roche, the news is buzzworthy.According to Roche, a legal team has developed two arguments that can be used by healthcare providers in federal court after the Administrative Law Judge (ALJ) process is completed. One argument is based on constitutional rights, while the other is a contradiction between the Medicare Program Integrity Manual and adopted federal law.During the next live edition of Monitor Mondays, Mr. Roche will discuss these two arguments briefly, and issue a call for providers who are at this stage in their appeals and might be interested in someone taking up their case on a contingency basis. Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to remedy Medicare Part B pay cuts made to 340B hospitals by issuing a lump-sum repayment to affected facilities.Last year, the U.S. Supreme Court ruled that those cuts, implemented by CMS from 2018 through most of 2022, were unlawful. Consequently, CMS proposed to offset the refunds by reducing payments for non-drug services to all hospitals under the 2024 Outpatient Prospective Payment System (OPPS). Commenting on this latest development impacting 340B hospitals during the next edition of Monitor Mondays will be the president and CEO for 340B Health, Maureen Testoni.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make 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

Although the 21st Century Cures Act was enacted in 2016, many hospitals today continue to struggle with effective implementation of its provisions and the goal of preserving patient access to medical records.Seven years later, however, meaningful guidance regarding its enforcement is here. One of the provisions requires developers not to engage in information blocking.Now that the guardrails are in place and the risks have been identified, Monitor Monday’s own physician and attorney Dr. John K. Hall will review the related enforcement actions and the penalties during the next live edition of the long-running Internet broadcast.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredriks

At least 1.3 million Medicaid enrollees have been disenrolled as of June 20, according to the Kaiser Family Foudation (KFF) “Unwinding Tracker.” This estimate could be an under-count, KFF admits, due to state recordkeeping details. Yet the major issue looms on the horizon: what will happen to those who have lost their Medicaid benefits? Could a tsuansmi of patients without health insurance soon appear at your hospital?During the next live edition of Monitor Mondays, Tony DiLuca, principal at Physician and Tactical Healthcare Services, LLC (PATHS) and a member of the Pennsylvania Department of Health and Human Services (HHS) Fee-for-Service Subcommittee, will report on the unwinding process of the enrollment, along with current updates and best practices.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will r

“Hospitals may be the most complex organizations in the world,” writes Edward M. Roche, scholar, United Nations consultant, and RACmonitor investigative reporter. “They are tasked with improving patient outcomes, controlling costs, and meeting sustainable environmental goals.”Roche, who will be the featured panelist during the next live edition of Monitor Mondays, believes that hospitals, in their quest for stability, have been nonetheless traumatized by the COVID-19 epidemic and a suffocating regulatory environment. Roche will also report on how many American hospitals now are in the midst of a digital transformation that is leading to an era of “smart hospitals” that will deliver unparalleled integration and improvements in all aspects of healthcare.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will rep

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare & Medicaid Services (CMS), U.S. Department of Justice (DOJ), and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) have increased audits to reduce improper payments, using predictive modeling and artificial-intelligence (AI) tools. Risk-based audits rose by 28 percent and prospective audits by 32 percent in 2022.To ease the burden on revenue cycle management (RCM) teams, a combination of automation, analytics tools, and denial management software can be used for hybrid audits, reducing denials and increasing reimbursements. During the next live edition of Monitor Mondays, Ritesh Ramesh, CEO for MDaudits, will report on how, by leveraging people and technology, internal audits can be conducted faster, errors caught earlier, and staff can focus more on training and optimizing revenue.Broadcast segments will als

This week, a disgraced Elizabeth Holmes was seen in media clips walking in the company of two unidentified men. Evidently, Holmes, who was convicted of fraud for her blood-testing start up, Theranos, turned herself in at a minimum-security prison in Texas to begin an 11-year prison term.All this media coverage raises the question: how easy is it to run afoul of the government regarding a wide range of statutes and regulations?Moreover, how far do you have to go to actually get to prison? During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine some recent convictions and sentences to help you assess your risk – keeping in mind that there’s no parole from federal prison.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Bonney Olney, director of Level of Care Service for R1 RCM, will make her Monday rounds, substituting for Dr. Ronald Hirsch.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson

Why the confusion and the apparent uptick in denials by Managed Care Organizations (MCOs) for skilled nursing facility (SNF) transfers?Returning to report on this vexing topic during the next live edition of Monitor Mondays will be Ben Kartchner, MD, a physician advisor who will join the broadcast to present the final installment in his two-part series being produced by RACmonitor and Monitor Mondays.Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors, exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Mary Beth Pace, vice president of Trinity Health, will be making her Monday Rounds, substituting for Dr. Ronald Hirsch.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mu

Medical necessity denials for skilled nursing facility (SNF) transfers by Managed Care Organizations (MCOs) are increasing at an astonishing rate.The reason seems to be a lack of understanding of the difference between skilled and non-skilled care. During an exclusive two-part series being produced by RACmonitor and Monitor Mondays, Ben Kartchner, MD will delve into this complex topic that is generating buzz, especially among physician advisors, many of whom appear to be struggling with post-acute care (PAC) and, specifically, SNF services. In fact, Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making h

Your medical staff office just notified you that a physician has been performing procedures without privileges for the past five years.No, it doesn’t happen all the time. But what should you do?Physician and attorney Dr. John K. Hall will walk you through the considerations and help you understand how much revenue might be in jeopardy during the next live edition of Monitor Mondays.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, 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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Cons

Hospital utilization and billing are notoriously challenging concepts for providers and case management staff because they frequently boil down to two, often conflicting points of view: what can be done per the rules, regulations, and contracts, and what should be done to provide the most effective care for a patient?  In a world where process standardization is imperative to maintain health system viability, but also where the practice of medicine remains an art, teams need a broad understanding of medical necessity and billing rules.Join us during the next live edition of Monitor Mondays when Dr. Juliet B. Ugarte Hopkins reports on where you can give and take and how to parse out the varying shades of grey.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, 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 Mullen, will report the latest news about auditors.Risk

The beleaguered False Claims Act, which traces its origins to the Civil War, came before the Supreme Court this past Tuesday, when the Court heard oral arguments in a consequential and closely watched case involving one of the Government’s most effective tools for fighting healthcare fraud. Specifically, the issue is whether and when a defendant’s contemporaneous subjective understanding or beliefs about the lawfulness of its conduct are relevant to whether it knowingly violated the Act. This case involves accusations that supermarket pharmacies Safeway and SuperValu overcharged Medicare and Medicaid for generic drugs by misrepresenting the usual and customary prices they charged for the drugs.During the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at the law offices of Constantine Cannon, will provide background and context on the case that the Court is expected to issue a ruling for in June, at the end of its term. Broadcast segments will also include these instantl

Recent highly publicized advances in artificial intelligence forecast the elimination of at least 30 percent of the healthcare workforce (probably more), including all generalist physicians. The astonishing scalability of information technology suggests that one to three data centers will be able to deliver medical advisory services to the entire population of the United States, according to Edward M. Roche, who will be reporting our lead story during the next live edition of Monitor Mondays.Roche is expected to report that as a country, America will see the debilitating cost of much healthcare being delivered today reduced to pennies and for all practical purposes delivered free of charge. But, cautions, Roche, such a game-changer will not be put in place without much resistance. So, who will be the winners and the losers in this new era of AI-driven healthcare? Register now to listen Monday.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Dr. James Kennedy, President

This year, as in past years, the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only List continues to confuse and bewilder so many healthcare professionals. And it’s little wonder: in 2021, CMS removed 500 surgical procedures from the List, only to reinstate most but not all of the procedures for 2022. Today, most Medicare and Medicaid plans follow the CMS Inpatient-Only List. But not all.Join us this coming Monday when Mary Beth Pace, our special guest on the next edition of Monitor Mondays, will serve as our guide, helping you avoid auditing pitfalls while traversing this tricky compliance territory of inpatient versus outpatient status.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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareh

It’s back: the Three-Midnight Rule.Created with the nation’s 1965 enactment of Medicare, the Rule provided that patients needed to have at least three consecutive midnights of inpatient care in an acute hospital setting before being admitted to skilled nursing facility (SNF). And then came the COVID-19 pandemic and the federal Public Health Emergency (PHE), and the rule was waived.Now, as the PHE is about to expire on May 11, the Rule is making a comeback. And that could pose problems for thousands of case and utilization managers across the country who are either out of practice with managing this Medicare requirement or have never in their careers had to address it.Join us during the next live edition of Monitor Mondays, when Juliet B. Ugarte Hopkins, MD, president of the American College of Physician Advisors, will be reporting on this new regulatory challenge and how to avoid the pitfalls associated with the inevitable audits that are likely to ensue.Broadcast segments will also include these instantly re

It’s the biggest healthcare story of the decade: up to 15 million individuals will soon be disenrolled from Medicaid, when the COVID-19 public health emergency (PHE) shuts down. Those who enrolled in Medicaid during the pandemic must re-enroll to keep their Medicaid coverage. Suddenly, your hospital could be overrun with uninsured patients.What’s being done about this issue, and what can you do?Join us during the next live edition of Monitor Mondays, when Dennis Jones will be reporting on the unwinding of the Medicaid Continuous Enrollment Provision of the Public Health Emergency (PHE). 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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the br

Imagine for a moment that the federal government, through one of its contractors, sends you money for services you don’t believe are covered benefits for a particular patient at your facility.But wait. Don’t react just yet.The best course of action might not be what you think, and it’s definitely not simple or straightforward, as you’ll learn during the next live edition of the long-running Monitor Mondays Internet radio broadcast. That’s when physician and attorney Dr. John K. Hall will explore the mysteries of Advance Beneficiary Notices (ABNs) and reverse false claims.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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his

Famed whistleblower attorney Mary Inman will return to the Monitor Mondays weekly Internet radio broadcast this coming Monday to report on a unique case in which a jury found that Precision Lens and its owner, Paul Ehlen, illegally paid kickbacks to ophthalmic surgeons to induce their use of the company’s products in cataract surgeries reimbursed by Medicare.The company was found to have submitted more than 64,000 false claims to Medicare, costing the program about $43 million in single damages. Precision Lens was found to have violated both the Anti-kickback Statute and the False Claims Act, which allows private individuals like the whistleblower in this case to sue in the name of the United States, alleging that the federal government has been defrauded.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 Mul

We at Monitor Mondays will begin a monthlong observance of National Doctors’ Day this coming Monday, March 6.Although the 90-year-old recognition of American physicians is March 30, during the next live edition of our weekly Internet radio broadcast we will recognize the contributions of Scott Ceule, MD, a physician advisor who, along with his team, helped create a transfer center at the University of Kansas Health System.Dr. Ceule will report on the process of creating a transfer center, while explaining the role of physician advisors in the transfer process; they are akin to gatekeepers in that they allow an organization to evaluate medical necessity, financials, and utilization review prior to accepting patients to the acute-care setting.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 Practus, will report the