Monitor Mondays

The U.S. Department of Justice (DOJ) reports that fraud against the U.S. under the federal False Claims Act (FCA) has amounted to $2.2 billion recovered in settlements and judgments for the 2022 fiscal year.   As in past years, FCA recoveries in the healthcare and life sciences industries continued to dominate enforcement activity in terms of the number and value of settlements, with healthcare fraud cases comprising 80 percent of total recoveries. These involved a wide range of issues, including Medicaid fraud, unnecessary and substandard care, kickbacks, and Medicare Advantage (MA) fraud. During the next edition of the weekly Internet radio broadcast, whistleblower attorney and Monitor Mondays regular contributor and panelist Mary Inman will report on healthcare enforcement trends from 2022, including a record-breaking $266.4 million reward to the whistleblower who reached a $900 million settlement with Biogen for kickback allegations, 10 years after filing his qui tam case.     Broadcast segments will also

The concern is real. And it’s growing.Providers could incur False Claims Act (FCA) liability when care that is delivered crosses over from “worth less” to “worthless.” You need to know where to draw the line. And that’s why we asked physician and attorney John K. Hall to explain, during the next live edition of Monitor Mondays.Broadcast segments will also include these instantly recognizable features:Special Report: Prominent healthcare attorney Andrew Wachler, managing partner at Wachler and Associates, will return to the broadcast to report on meeting the 90-day statutory timeframe for administrative law judge (ALJ) hearings.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 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.Legis

What constitutes inpatient status? Should patient status be determined by guidelines or screening criteria? Or just the facts?Revisiting what is certain to be considered an evergreen issue, Dr. Andrew Markiewitz will return to report the lead story for the next upcoming live edition of Monitor Mondays to continue discussing the vexing topic of patient status. Dr. Markiewitz is expected to report that screening criteria, scoring systems, and guidelines help determine medical necessity and patient status. But, he will add, although these metrics are used by payers, they are not treatment protocols. “We need to base our care on the patient in front of us,” advises Dr. Markiewitz.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 latest news about auditors. Risky Business: Healthcare attorney D

Healthcare providers nationwide are facing menacing interactions with auditors that, like hungry predators, are looking at submitted claims for the slightest evidence of omission or commission as the justification to pounce.But it’s not so much the actual auditing as the long and wearisome journey of appeals – and the very real possibility of financial disaster. Although medical record auditing is not new, its frequency and alleged abuses contribute to a tell a tale of tragedy for America’s healthcare system.That is why each and every Monday morning, Monitor Mondays has been alerting its listeners as to consequences of auditing gone awry – but also reporting on preventative measures providers can take to help their facilities avoid takebacks and fines.This coming Monday, Monitor Mondays will continue with its reporting on auditors behaving badly.That’s when listeners will hear of complication and comorbidity (CC) risk scores: a relative measure of the average health (or lack of health) for a Medicare benefici

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Never-before-seen data has revealed that Hierarchical Condition Category (HCC) risk scores could predict under- or over-coding – and it will be the primary topic of discussion during the next live edition of Monitor Mondays.That’s when senior healthcare analyst Frank Cohen will report on his findings. The HCC risk score is a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care. Out of this model was born clinical documentation improvement, or CDI – a push to improve documentation so that it improves the reporting of diagnoses and procedures, thereby optimizing the scores. But with this comes the opportunity for abuse. So, can the HCC risk score help predict whether a provider is under-coding, over-coding, or coding optimally? Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his

In May 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a report claiming that 25 percent of Medicare patients experienced adverse events during their October 2008 hospital stay.“That’s a staggering number,” said John K. Hall, MD, in an email to RACmonitor. “So, what does it mean, and what should providers expect from other auditors and government agencies?”During the next live edition of Monitor Mondays, physician and attorney Dr. Hall will review the report and offer suggestions to prepare if the OIG comes knocking at your door.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 latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast

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No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual.As the rest of the nation’s healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here and in RACmonitor.Broadcast segments will include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds, during which he will report an exclusive auditing story in which he details news about a move by the Centers for Medicare & Medicaid Services (CMS) to clamp down on Medicare Advantage (MA).The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report th

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In October, after 18 months in the news cycle, Optum closed its controversial acquisition of Change Healthcare.  While the healthcare industry intensely watched the merger beat a challenge from the U.S. Department of Justice (DOJ) on antitrust grounds, that  news story was far from the only newsworthy acquisition that Optum has made.  With far less public discourse than the Change Healthcare acquisition, Optum has made 18 acquisitions and six investments in recent years. The company has spent more than $30 billion on acquisitions in multiple sectors. Simply stated, Optum is embedded in every nook and cranny of healthcare and is the keeper of big data and analytics for employers, health plans, state and federal agencies and providers. So the question remains: Too big to fail? Reporting our lead story during the next live edition of Monitor Mondays will be Jerilyn Morrissey, MD, senior vice president of clinical and regulator affairs for Versalus Health.Other segments will include these instantly recognizable b

Are Medicare auditors similar to ancient hunting parties roaming the tundra for wild game? Are audits applied equally and randomly across all healthcare providers, or is there intelligent design directed by a  hidden network of influencers, working behind the scenes and shifting first to one area, then another?During the next live edition of Monitor Mondays, Edward M. Roche, RACmonitor’s investigative reporter, is going to look at the data to see if there are patterns in auditing and settlements – and if possible, identify the drivers behind these waves of aggressive activity.Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, 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.SDoH Report: Tiffany Ferguson, a subject-matter expert on the social deter

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We’ve all watched in awe as the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) began investigating the Medicare Advantage plans. Many were thinking, “it’s about time the payers get some of the heat providers feel.” But there’s something even better, according to most. That’s when the OIG investigates the government.During the next live edition of Monitor Mondays, physician-attorney Dr. John K. Hall reviews an OIG audit of Medicare contractors and the Centers for Medicare & Medicaid Services (CMS). He’ll also explain what this means for providers.Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, 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.SDoH Report: Tiffany Ferguson, a subject matter expert on the s

Most healthcare providers are swimming in shark-infested waters these days, ever-watchful for dorsal fins that signal imminent danger.  At first there were the Recovery Auditors (RAs), created by the Centers for Medicare & Medicaid Services (CMS), to correct Medicare billing submitted by providers for services rendered to Medicare beneficiaries. And now, nearly two decades later, the RAs have been joined by several other auditors, and healthcare has quickly become a dangerous and expensive environment, especially given a new breed of sharks: the Medicare Advantage Organizations (MAOs), whose primary mission is to save money by denying claims in the name of compliance.Join us next Monday for another live edition of the long-running Monitor Mondays Internet broadcast for a news round-up, and to learn of more lurking dangers and how to protect your facility’s revenue while remaining compliant, even amid all the turmoil.Other segments will include these instantly recognizable broadcast features:OIG Report: Mo

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Along the gulf shores of Mobile Bay in Alabama, at the crack of dawn you might hear shouts of jubilation from early risers there to witness flounder, soft-shell blue crabs, and gulf shrimp beach themselves due to the upward movement of oxygen-deprived bottom waters. The aftermath is a bounty of seafood on the sandy beaches, and hence the local dish known as “jubilee.”Yet when it comes to local healthcare providers dealing with the Recovery Auditor (RA) Cotiviti, there is no jubilance – as you will hear Jennifer Bartlett explain during the next live edition of Monitor Mondays. Bartlett will report on the difficulty she and her team, along with other providers, face as they cope with the vagaries of one of the largest of the RAs in the U.S. Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in th

The Medicare Physician Fee Schedule Final Rule for 2023 includes a provision for telehealth services – this following the temporary expansion of telehealth to beneficiaries during the COVID -19 public health emergency (PHE) that began March 1, 2020. Once the temporary PHE waivers terminate, what are the plans the Centers for Medicare & Medicaid Services (CMS) has for covering telehealth services for Medicare beneficiaries?Join 3M consultant Colleen Deighan-Ejak during the next live edition of Monitor Mondays, when she will outline what is included in the Final Rule for Medicare telehealth services.  Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, 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.SDoH Report: Tiffany Ferguson, a subject matte

Healthcare attorney Andrew Wachler is an audit warrior, with war stories that will make you cringe in absolute disbelief.And during the next live edition of Monitor Mondays, Wachler will tell some of these stories, sharing lessons to learn from his experience defending provider clients. He’ll report how failure to appeal a target, probe and educate (TPE) audit could establish a “pattern or practice of submitting claims fail to meet Medicare requirements” for the purpose of revocation of Medicare billing privileges.Wachler will also share challenges related to lifting a Medicare payment suspension implemented across multiple Medicare Administrative Contractor (MAC) jurisdictions.Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’

Rumors, as they tend to sometimes, are spreading fast. Are there significant leadership changes coming within the largest Medicare Advantage (MA) plans for many beneficiaries in the mid-South region of the country?Spend time with Jennifer Bartlett, longtime systems coordinator at Infirmary Health System in Mobile, Alabama, and it becomes clear that there could be a whole new ballgame, with new players. Are MA plans recalibrating their auditing approaches to providers? Could the payers be reacting to accountability tools?Join us during the next live edition of Monitor Mondays, when Bartlett will report on her experience with Humana and UnitedHealthcare – and how her Audit Activity Reports are the best tool to have in your toolkit to level the playing field shared by facilities and these gargantuan MA plans.Other segments will include these instantly recognizable broadcast features:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors