Sinopsis
Join Chuck Buck every Monday when he welcomes RACmonitor contributing editors and special guests for the latest regulatory audit news and information from CMS, OIG and OMHA. And gain valuable context and perspective that can only be found when youre listening to the long-running and popular Monitor Mondays. Register to attend live here: http://utm.io/ub1oR
Episodios
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The Tables Are Turning: OIG Sets Sights on Medicare Advantage DRG Validation Denials
17/10/2022 Duración: 30minDRG validation denials by Medicare Advantage (MA) plans have become a widespread and increasing concern for many hospitals.But these denials may be the result of a misapplication of standard diagnostic criteria by a reviewer. Now, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is turning the DRG validation denials back on MAs. The OIG recently published several diagnosis-validation audits of MAs and recommended recoupment for exactly the same diagnoses the MAs have denied for providers.But what can we learn from these audits to help manage diagnosis denials by payers? Does this portend new MA tactics? Sitting in for Dr. Ronald Hirsch during the next edition of Monitor Mondays will be our own physician and attorney, Dr John K. Hall, who will offer his take on the future of diagnosis denials and how to prepare.Other segments will include these instantly recognizable broadcast segments:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practu
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Mary's Bookclub: Nuclear Medicine & PET Coder
12/10/2022 Duración: 02minListen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Nuclear Medicine & PET Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.
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Exclusive: Some Extrapolation Estimates Vacated
10/10/2022 Duración: 31minWhile the pandemic may have shielded healthcare providers from intrusive recoupment audits, the auditing break was but temporary. Starting in August of 2021, UPIC, TPE, RAC and other audits started back up and the contractors had a lot of catching up to do. At the same time, the administrative law judges were under enormous pressure to get the backlog of cases completed by the end of 2022. The result? A paradigm shift in how hearings were conducted and the impact that has on outcomes. Senior healthcare analyst and RACmonitor correspondent Frank Cohen will talk about how these changes have benefited providers in getting judges to vacate the extrapolation estimates. Other segments will include these instantly recognizable broadcast segments: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 t
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False Claims Act: Biogen to Pay $900 Million: Whistleblower Gets $250 Million
03/10/2022 Duración: 31minAccording to the U.S. Department of Justice, pharmaceutical giant Biogen will pay $900 million to settle a lawsuit that alleged the company gave doctors kickbacks to encourage them prescribe its drugs. The settlement resolves a lawsuit filed and litigated by former Biogen employee Michael Bawduniak against Biogen under the qui tam or whistleblower provisions of the federal False Claims Act. Famed whistleblower Mary Inman will report this story during the next live edition of Monitor Mondays. Inman, reporting from her London office, is expected to provide details on the settlement.Other segments will include these instantly recognizable broadcast segments: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 d
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Beware: Enforcement of the Hospital Price Transparency Rule
26/09/2022 Duración: 28minBeware of enforcement action by the Centers for Medicare & Medicaid Services (CMS) for noncompliance of the Hospital Transparency Rule which took effect January 2021. The rule requires hospitals to make public—in machine readable files—prices for certain items and services. Failure to comply could result in fines as in the case of two Georgia hospitals. Make no mistake. CMS is laying down the law. Reporting our lead story during the next live edition of Monitor Mondays will be Govind Goyal, Executive Vice President at Panacea Healthcare Solutions, and a subject matter expert on Hospital Price Transparency Rule.Other segments will include these instantly recognizable broadcast segments: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 su
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Mary's Bookclub: CT/MR Coder
21/09/2022 Duración: 01minListen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of CT/MR Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.
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Medicare: The New Drug Price Negotiator
19/09/2022 Duración: 31minProvisions in the newly enacted Inflation Reduction Act represent some of the most significant changes to the healthcare system that have taken effect in the past decade. Maureen Testoni, president and CEO of 340B Health, will review some of the new law’s drug pricing elements. They include provisions for Medicare to start negotiating the prices it will pay for certain drugs for the first time in the program’s history. How these drug pricing changes play out will affect the entire healthcare system, including the safety-net providers who already receive discounted prices on some prescription drugs.Other segments will include these instantly recognizable broadcast segments:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.The News Report: Dennis Jones, Patient Financial Services at Montefiore Nyack Hospital will report on the single payer proposal.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of
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Medical Necessity: The Necessity of Defining the Dilemma
12/09/2022 Duración: 37minA national debate is raging across America involving providers and payers. The vexing issue is of medical necessity—and the search for consensus on a definition for this simple yet complicated issue. During the next live edition of Monitor Mondays, Tim Brundage, MD will set the table for a robust discussion. Also on the rundown, the growing presence of private equity firms in healthcare. Given that they see healthcare as an attractive target for its investments, could their laser focus on improving profit margins potentially cross the line into Medicare fraud? Famed whistleblower attorney Mary Inman will report on False Claims Act cases that the U.S. Department of Justice has and continues to pursue against private equity for such alleged practices.Other segments will include these instantly recognizable broadcast segments: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, shareho
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Mary's Bookclub: Peripheral & Cardiology Coder
01/09/2022 Duración: 02minListen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Peripheral & Cardiology Coder. Listen in to find out why this textbook could be a great addition to add to your essential library.
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Medicare Advantage: OIG Warns: Don’t Deny Payments
29/08/2022 Duración: 32minThe warning was shot across the bow of Medicare Advantage Organizations (MAOs). The U.S. Department of Health and Human Services (HHS) Office of Inspector (OIG), in a report to the Centers for Medicare & Medicaid Services (CMS) raised concerned that MAOs could be denying prior authorizations requests in an attempt to increase profits.CMS agreed to the report and, on Aug. 3, issued new guidance on the appropriate use of MAO clinical criteria for medical necessity reviews along with numerous revisions.Reporting on this developing story during the next live edition of Monitor Mondays will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital.Other segments will include these instantly recognizable broadcast segments: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 broadc
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Medicare Telehealth: The Perils of Fraud and Abuse
22/08/2022 Duración: 31minThe public health emergency caused by Covid-19 compelled the U.S. Department of Health and Human Services to loosen the regulations to fund more telehealth services, and these "temporary" policies may be extended. But what many may not know is that the United States has been experimenting with telehealth for 122 years, since the turn of the previous century, according to Edward M. Roche will report the lead story during the next live edition of Monitor Mondays. Roche, the Monitor Mondays investigative reporter, will review some of this history, and highlight the emerging challenges of future technologies and the continued peril of fraud and abuse. Other segments will include these instantly recognizable broadcast segments: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 trademar
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The Unusual Autopsy You Need to Hear
15/08/2022 Duración: 30minAlthough the “Inflation Reduction Act (H.R. 5376)” is still alive and headed to President Biden’s desk for his signature, there are provisions, deep inside the proposed legislation that will lower health care and prescriptions drug costs and could impact beneficiaries of some government-sponsored health insurance plans.During the next live edition of Monitor Mondays, physician and attorney Dr John K. Hall will autopsy the bill, dissecting the legislation to uncover some of the relevant provisions while adding fine points and adds necessary context to this important legislation.Other segments will include these instantly recognizable broadcast segments: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 dete
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False Claims Act: Whistleblower Blows the Whistle on Charity Donation
08/08/2022 Duración: 31minWithout admitting guilt, a Florida health system entered into a $20 million settlement under the False Claims Act with the U.S. Department of Justice (DOJ) to resolve allegations that it made donations to increase Medicaid contributions. The whistleblower filed the suit alleging that the system made improper cash donations to a local charity in a scheme to increase the system’s Medicaid funding. At a time when the False Claims Act is under scrutiny, this story—to be reported by famed whistleblower attorney Mary Inman—is relevant and consequential. What lessons can be learned from this not-to-charitable scheme? Listen and learn when Inman, a partner in law office of Constantine Cannon, joins the next live edition of Monitor Mondays.Other segments will include these instantly recognizable broadcast segments: 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
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Mary's Bookclub: Essentials of Interventional Radiology Coding
03/08/2022 Duración: 03minListen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Essentials of Interventional Radiology Coding. Listen in to find out why this textbook could be a great addition to add to your essential library.
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The UPICs: The Mean, the Bad and the Ugly
01/08/2022 Duración: 31minLike unwanted mushrooms bursting forth from your lawn, the Zone Program Integrity Contractors (ZPICs) appear to be on steroids. Their audits are aggressive disruptors in the vast auditing landscape in which providers continue to provide care and bill for the services they provide. In fact, the recent uptick in their audit activities is in the Medicaid arena. UPICs— the Centers for Medicare & Medicaid Services (CMS) contractors tasked with integrating program integrity functions for audits and investigations across both Medicare and Medicaid—are now coordinating and performing more Medicaid audits.During the next live edition of Monitor Mondays, prominent healthcare attorney Andrew Wachler, the managing partner of Wachler and Associates, will be reporting on the ZPIC audits he is encountering while offering steps providers and suppliers can take to protect their reimbursement from recoupment.Other segments will include these instantly recognizable broadcast segments:Post Payment Audits: Kevin Lasser, CEO o
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Recent Supreme Court Decision Likely to Rattle Healthcare
25/07/2022 Duración: 30minThe recent decision by the Supreme Court to invoke the major questions doctrine to nullify an agency regulation in the case of West Virginia versus the Environmental Protection Agency seems to indicate the court’s trend toward increasingly strict interpretation of statutes. The possibility that new, or even well-established, regulations may be overturned means that healthcare regulation could change drastically on extremely short time scales with no direct input from stakeholders. During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall explains the major questions doctrine and its potential impact on healthcare.Other segments will include these instantly recognizable broadcast segments:The RAC Report: Healthcare attorney Knicole Emanuel, a 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’s happening at the intersection o
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Too Big to Fail: Perception of Payer Infallibility
18/07/2022 Duración: 30minAre commercial payers too big to fail? Do they operate with the sense of infallibility? Case in point: UnitedHealthcare Group, which according to its earnings report, posted $4.1 billion in profits in the fourth quarter of 2021. Is the playing field level between payers and providers? For example, during the review of rejected claims does UnitedHealthcare or any private company such as this have advantages over a healthcare provider compared to what it would be if they were using the regular administrative law judge process? During the next live edition of Monitor Mondays RACmonitor investigative reporter Edward M. Roche returns to the broadcast to discuss the rights of providers in the two different appeals processes.Other segments will include these instantly recognizable broadcast segments: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 Fr
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Mary's Bookclub: Cardiac Rhythm Management Coder
13/07/2022 Duración: 02minListen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Cardiac Rhythm Management Coder. Listen in to find out why this textbook could be a great edition to add to your essential library.
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What’s the Missing Ingredient in Medicare Audits?
11/07/2022 Duración: 30min“Good enough for government work,” was once the saying among cynical factory workers. And yet today in healthcare, precision in Medicare statistical analysis really matters. If overpayments are found, then the extrapolation recoupment number will go up; if underpayments are found, the extrapolation will go down.Listen and learn during the next live edition of Monitor Mondays when RACmonitor investigative attorney Edward M. Roche will report that his team routinely finds Medicare auditors handing in extrapolations that can be plus or minus 10, 15, 20, 30 percent – or even worse.“That is somewhere between 25 and 85 percent,” wrote Roche recently in RACmonitor. “But that seems to be good enough for government work.”Precision in Medicare auditing is a prerequisite. But, sadly—as you’ll learn from Roche—that’s not always the case.Other segments will include these instantly recognizable broadcast segments:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the lates
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Front and Center: Medicare Advantage Audits, Medical Necessity to Ensure Payments, and the Two-Midnight Rule
06/07/2022 Duración: 09minMedicare Advantage Audits, Establishing Medical Necessity to Ensure Payments, and the Two-Midnight Rule are three outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.