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 &amp; 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 latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

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 &amp; 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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.</li></ul>

Proposed Expansion of Medicaid RACs Includes Focus on Managed Care Payments

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 about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Cate Brantley, state legislative affairs analysis for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Cate Brantley, state legislative affairs analysis for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

New Developments for Defeating Statistical Extrapolations Revealed

The Centers for Medicare &amp; 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 law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Matthew Albright, chief legislative affairs analysis for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

The Centers for Medicare &amp; 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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Matthew Albright, chief legislative affairs analysis for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

$9 Billion Refund to 340B Hospitals at Risk

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 Fredrikson &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.

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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.</li></ul>

Enforcement and Penalties, Guardrails and Risks: Understanding the 21st Century Cures Act

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 report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Cate Brantley, a legislative analyst for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

The Big Worry. The Big Unwind: Medicaid Disenrollment Keeps Rolling Along

“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 report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, 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 Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

“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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

How Suffocating Regulations Are Leading to Smart Hospitals

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare &amp; 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 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 Kyla Wonder, 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 &amp; Byron, will join the broadcast with his trademark segment.Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare &amp; 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 also include these instantly recognizable features:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds. </li><li>The RAC Report: Healthcare attorney Kyla Wonder, partner at the law firm of Nelson Mullins, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Byron, will join the broadcast with his trademark segment. </li><li>Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

How Staffing Shortages Increase Audits

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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, will join the broadcast with his trademark segment.Legislative Update: Cate Brantley, JD, a legislative analyst for Zelis, will report on current healthcare legislation.

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:<ul><li>Monday Rounds: Bonney Olney, director of Level of Care Service for R1 RCM, will make her Monday rounds, substituting for Dr. Ronald Hirsch. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, will join the broadcast with his trademark segment. </li><li>Legislative Update: Cate Brantley, JD, a legislative analyst for Zelis, will report on current healthcare legislation. </li></ul>

Running Afoul of Federal Regulations

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 Mullen, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, will join the broadcast with his trademark segment.Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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:<ul><li>Monday Rounds: Mary Beth Pace, vice president of Trinity Health, will be making her Monday Rounds, substituting for Dr. Ronald Hirsch. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, will join the broadcast with his trademark segment. </li><li>Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

Smart Strategies to Avoid Denials of SNF Transfers

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 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 &amp; Bryon, will join the broadcast with his trademark segment.Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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:<ul><li>Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will be making his Monday Rounds. </li><li>The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, will report the latest news about auditors. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, will join the broadcast with his trademark segment. </li><li>Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation. </li><li>The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.</li></ul>

How to Avoid Managed Care Denials for SNF Transfers

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 you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: https://racmonitor.medlearn.com/racmonitor/podcasts/

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 you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: <a href="https://racmonitor.medlearn.com/racmonitor/podcasts/" rel="nofollow" target="_blank">https://racmonitor.medlearn.com/racmonitor/podcasts/</a>

Monitor Mondays

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 broadcast rundown also will include: Monday  Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory  Services, makes his Monday Rounds with another installment of his  popular segment.  Monday Focus: Michael Salvatore, MD, FACP   reports on the ancient practice of alchemy and how its modern-day equivalency is  turning health into disease. Dr. Salvatore is the physician advisor and medical  director of the palliative care team at Beebe Healthcare in Delaware. Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron  continues his  reporting on the perennial question, “should I refund an overpayment?” He will  pose the question as a listener quiz.  Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy  Beckley and Associates,  reports on all the latest hot topics. Monitor with us™ 

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 broadcast rundown also will include:<ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. </li></ul><ul> <li>Monday Focus: Michael Salvatore, MD, FACP reports on the ancient practice of alchemy and how its modern-day equivalency is turning health into disease. Dr. Salvatore is the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware.</li></ul><ul> <li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron continues his reporting on the perennial question, “should I refund an overpayment?” He will pose the question as a listener quiz. </li></ul><ul> <li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics. Monitor with us™ </li></ul>

Anatomy of an Alleged False Claims Act Violation: The Providence Health & Services Lawsuit

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&amp;M guidelines by CMS.   Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron  reports on  another example of a potentially troublesome issue that could pose a risk to  your facility.   Monday  Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory  Services, makes his Monday Rounds with another installment of his  popular segment. Dr. Hirsch will also present the Monitor Mondays Listener  Survey.  Monitor with us™

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: <ul> <li>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&amp;M guidelines by CMS. </li></ul> <ul> <li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.</li> </ul> <ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also present the Monitor Mondays Listener Survey.</li> </ul> Monitor with us™

2019 Medicare Physician Fee Schedule and the Outpatient Prospective Payment System:  Analyzing the Impacts on Providers

 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 broadcast rundown also will include:  RAC Report: Healthcare attorney Knicole Emanuel, a partner  at the Potomac Law Group,  has the latest news on the Recovery Audit  Contractors (RACs).   Hot Topics: Monitor Mondays senior correspondent  Nancy Beckley, president and CEO of Nancy Beckley and Associates,  reports on  the 2019 Proposed Medicare Physician Fee Schedule’s impact on outpatient  therapy.    Medicare Advantage Report: Monitor Mondays national correspondent  J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.   Monday  Rounds: Ronald Hirsch, MD, vice president of R1  Physician Advisory Services, reports on the 2019 Proposed Medicare  Physician Fee Schedule released by CMS on Thursday.  Monitor with us™

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 broadcast rundown also will include: <ul> <li>RAC Report: Healthcare attorney Knicole Emanuel, a partner at the Potomac Law Group, has the latest news on the Recovery Audit Contractors (RACs).</li> </ul> <ul> <li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the 2019 Proposed Medicare Physician Fee Schedule’s impact on outpatient therapy. </li> <li>Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.</li> </ul> <ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, reports on the 2019 Proposed Medicare Physician Fee Schedule released by CMS on Thursday.</li> </ul> Monitor with us™

Case Management in the ED: Getting Patient Status Right the First Time

“Podiatrists should not be discriminated against any  further. E&amp;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 &amp;  Medicaid Services’ (CMS’s) proposed E&amp;M reimbursement changes in the  recently posted 2019 Medicare Physician Fee Schedule.  “If Medicare is going to change E&amp;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’t require the presence of a physician. Reporting on this developing story on this edition of Monitor Mondays will be Jeffrey D. Lehrman, DPM, diplomate of the  American Board of Foot and Ankle Surgery.  The broadcast rundown also will include:  Monday  Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory  Services, makes his Monday Rounds with another installment of his  popular segment.    Monday Focus: The proposed  E&amp;M changes are expected to impact providers’ bottom lines. But by how  much? Senior healthcare analyst Frank Cohen, director of business intelligence  and analytics for DoctorsManagement, has done the math and  shares his  analysis.    Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron  reports on  another example of a potentially troublesome issue that could pose a risk to  your facility.    False Claims Act Report: Nationally  recognized whistleblower attorney Mary A. Inman, partner at Constantine  Cannon’s London office, has an update on the $65 million settlement by Prime  Healthcare to resolve allegations that its hospitals submitted false Medicare  claims.    Medicare Report:  Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare  consultant for DoctorsManagement, continues to report on the vexing issue  of Medicare compliance.   Monitor with us™

“Podiatrists should not be discriminated against any further. E&amp;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 &amp; Medicaid Services’ (CMS’s) proposed E&amp;M reimbursement changes in the recently posted 2019 Medicare Physician Fee Schedule. “If Medicare is going to change E&amp;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’t require the presence of a physician. Reporting on this developing story on this edition of Monitor Mondays will be Jeffrey D. Lehrman, DPM, diplomate of the American Board of Foot and Ankle Surgery. The broadcast rundown also will include: <ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. </li> </ul> <ul> <li>Monday Focus: The proposed E&amp;M changes are expected to impact providers’ bottom lines. But by how much? Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, has done the math and shares his analysis. </li> </ul> <ul> <li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. </li> </ul> <ul> <li>False Claims Act Report: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on the $65 million settlement by Prime Healthcare to resolve allegations that its hospitals submitted false Medicare claims. </li> </ul> <ul> <li>Medicare Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare compliance. </li> </ul> Monitor with us™

CMS, Are You Listening? Podiatrists React Negatively to Proposed E&M Changes

Pick up any healthcare news feed or relevant state or federal initiative, and no doubt you will see the "surprise billing" issue headlining. The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as "non-emergent." Prudent acts among patients are ignored, common sense is discarded, and ethical conduct is cast aside in order to insist that patients pay astronomical bills for services that truly constitute emergency care. These battles can take years. One such case will be discussed during this edition of Monitor Mondays; reporting our lead story will be Holly Louie, herself once an emergency department nurse.Other segments to appear on the broadcast include:Monday Focus: Bogus Charity Write-offs: The Patient Protection and Affordable Care Act (PPACA) created a new provision in Section 501 of the Internal Revenue Code that applies to facilities licensed as hospitals under state law, with new requirements for uncompensated care. The law also imposed new reporting requirements on hospitals. Running afoul of this issue could be a significant compliance violation, as you’ll learn when Timothy Powell reports on what many experts believe could be a major compliance bust.United Behavioral Health Lawsuit: On Tuesday, a federal court in California found that United Behavioral Health (UBH) denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral healthcare. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, will have the latest news on this major story.Extrapolation Changes: The Centers for Medicare &amp; Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, reports on the changes and what they mean to providersRisky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Pick up any healthcare news feed or relevant state or federal initiative, and no doubt you will see the "surprise billing" issue headlining. The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as "non-emergent." Prudent acts among patients are ignored, common sense is discarded, and ethical conduct is cast aside in order to insist that patients pay astronomical bills for services that truly constitute emergency care. These battles can take years. One such case will be discussed during this edition of Monitor Mondays; reporting our lead story will be Holly Louie, herself once an emergency department nurse.Other segments to appear on the broadcast include:<ul><li>Monday Focus: Bogus Charity Write-offs: The Patient Protection and Affordable Care Act (PPACA) created a new provision in Section 501 of the Internal Revenue Code that applies to facilities licensed as hospitals under state law, with new requirements for uncompensated care. The law also imposed new reporting requirements on hospitals. Running afoul of this issue could be a significant compliance violation, as you’ll learn when Timothy Powell reports on what many experts believe could be a major compliance bust. </li><li>United Behavioral Health Lawsuit: On Tuesday, a federal court in California found that United Behavioral Health (UBH) denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral healthcare. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, will have the latest news on this major story. </li><li>Extrapolation Changes: The Centers for Medicare &amp; Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, reports on the changes and what they mean to providers </li><li>Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.</li></ul>

Removing the Surprise from ED Billing

It’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare &amp; Medicaid Services (CMS) included a reduction in the base payment rate of 8.01 percent in the Patient-Driven Groupings Model (PDGM) of the 2020 Home Health Prospective Payment System Rate Update.Returning to Monitor Mondays is William Dombi, president of the National Association for Home Care and Hospice, who will provide a regulatory update for his association as its members prepare for another year of audits.Other segments to be featured on the broadcast include the following:Monday Focus: What are likely to be three major audit issues in 2020? Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reveals his pick of the top challenges you and your team will face in 2020.RAC Report: Healthcare attorney Knicole Emanuel reports on the latest activities by the Recovery Audit Contractors (RACs) and other third-party Medicare claims auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, unveils his 2019 Hirsch’s Heroes: individuals who, in his judgment, made outstanding contributions in the world of healthcare over the last year.

It’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare &amp; Medicaid Services (CMS) included a reduction in the base payment rate of 8.01 percent in the Patient-Driven Groupings Model (PDGM) of the 2020 Home Health Prospective Payment System Rate Update. Returning to Monitor Mondays is William Dombi, president of the National Association for Home Care and Hospice, who will provide a regulatory update for his association as its members prepare for another year of audits. Other segments to be featured on the broadcast include the following:<ul><li>Monday Focus: What are likely to be three major audit issues in 2020? Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reveals his pick of the top challenges you and your team will face in 2020. </li><li>RAC Report: Healthcare attorney Knicole Emanuel reports on the latest activities by the Recovery Audit Contractors (RACs) and other third-party Medicare claims auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. </li><li>SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson &amp; Bryon, joins the broadcast with his trademark segment, in which he reports on problematic issues facing providers.  </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, unveils his 2019 Hirsch’s Heroes: individuals who, in his judgment, made outstanding contributions in the world of healthcare over the last year.</li></ul>

Home Health and Hospice: State of the Union

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare &amp; Medicaid Services (CMS) released an updated memo on the subject on Thursday.The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story during the next edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare.The broadcast rundown also will include:Monday Focus Report: Blockchain: Distributed ledger systems (DLS), also known as blockchain, will be the Monday Focus when RACmonitor investigative reporter and New York attorney Edward Roche will report on new healthcare technologies we can expect to see in 2019.War on Drugs: The U.S. Department of Justice announced this week that Walgreens Boots Alliance agreed to pay $269.2 million to settle two healthcare fraud lawsuits alleging that Walgreens overbilled the government. In a related matter, United HealthCare Services filed a federal lawsuit last week against more than 40 drug companies, alleging they violated federal and state antitrust laws. Whistleblower attorney Mary Inman will report on both lawsuits.Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment “Risky Business,” in which he reports on problematic issues facing providers.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare &amp; Medicaid Services (CMS) released an updated memo on the subject on Thursday.The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story during the next edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare.The broadcast rundown also will include:<ul><li>Monday Focus Report: Blockchain: Distributed ledger systems (DLS), also known as blockchain, will be the Monday Focus when RACmonitor investigative reporter and New York attorney Edward Roche will report on new healthcare technologies we can expect to see in 2019. </li><li>War on Drugs: The U.S. Department of Justice announced this week that Walgreens Boots Alliance agreed to pay $269.2 million to settle two healthcare fraud lawsuits alleging that Walgreens overbilled the government. In a related matter, United HealthCare Services filed a federal lawsuit last week against more than 40 drug companies, alleging they violated federal and state antitrust laws. Whistleblower attorney Mary Inman will report on both lawsuits. </li><li>Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment “Risky Business,” in which he reports on problematic issues facing providers. </li><li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.</li></ul>

TKA 2.0: CMS Updates Total Knee Arthroplasty, Again

Contentious and confusing, the Centers for Medicare &amp; Medicaid Services (CMS) Hospital Price Transparency Rule will become effective Jan. 1, 2021.On the surface, the requirements are straightforward: hospitals and health systems must make accessible all negotiated managed care rates in a machine-readable format, along with a list of 300 “shoppable” items –non-urgent, high-volume items and services – on their website or via an interactive tool for consumers. But below the surface lurks confusion. That is why we asked Frederick Stodolak, the president of Panacea Healthcare and a subject matter expert on hospital pricing, to be our special guest during this edition of Monitor Mondays.Other segments featured on the podcast:Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will join the broadcast as a permanent guest and reports on current healthcare legislation: either proposed, pending, or passed, and its anticipated consequences.RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. SDoH Report: Ellen Fink-Samnick, has the latest on the social determinants of health (SDoH) specifically with pediatrics.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson &amp; Bryon, will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Contentious and confusing, the Centers for Medicare &amp; Medicaid Services (CMS) Hospital Price Transparency Rule will become effective Jan. 1, 2021. On the surface, the requirements are straightforward: hospitals and health systems must make accessible all negotiated managed care rates in a machine-readable format, along with a list of 300 “shoppable” items –non-urgent, high-volume items and services – on their website or via an interactive tool for consumers. But below the surface lurks confusion. That is why we asked Frederick Stodolak, the president of Panacea Healthcare and a subject matter expert on hospital pricing, to be our special guest during this edition of Monitor Mondays. Other segments featured on the podcast:<ul><li>Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will join the broadcast as a permanent guest and reports on current healthcare legislation: either proposed, pending, or passed, and its anticipated consequences. </li><li>RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors.  </li><li>SDoH Report: Ellen Fink-Samnick, has the latest on the social determinants of health (SDoH) specifically with pediatrics. </li><li>Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrickson &amp; Bryon, will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.</li></ul>

Hospital Price Transparency:  Clearing Up the Compliance Confusion

The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the institution – and obviously, the referral from the community will have a lower payment. Judith A. Stein, JD, executive director of the Center for Medicare Advocacy, reports on this story, along with William Dombi, Esq. president of the National Association of Home Care and Hospice, during this edition of Monitor Mondays.Other segments to appear during the live broadcast include:RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, and will report on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. 

The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the institution – and obviously, the referral from the community will have a lower payment. Judith A. Stein, JD, executive director of the Center for Medicare Advocacy, reports on this story, along with William Dombi, Esq. president of the National Association of Home Care and Hospice, during this edition of Monitor Mondays.Other segments to appear during the live broadcast include:<ul><li>RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. </li><li>SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey. </li><li>Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, and will report on problematic issues facing providers. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. </li></ul>

Changes in the Works for Home Care Providers

Many hospitals are likely in the throes of preparing to implement the Centers for Medicare &amp; Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, including how to reconcile the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The new rule becomes effective Friday, Nov. 29, 2019.“CMS has spent the last two years working on the IMPACT Act, and they are now ready to implement,” reports Mary Beth Pace, vice president of care management at Trinity Health. “Does the CoP resemble anything akin to what you thought they would come out with? It does not to us. Let me reflect on our initial shock, and then our action.”For a field report on how one major health system is preparing for this major new policy, RACmonitor has invited Ms. Pace to be the special guest during the next edition of Monitor Mondays.Other segments to be featured on the broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel will report on the status of the Medicaid lawsuit filed after more than two dozen plaintiff Virginia behavioral healthcare providers had their managed care contracts terminated by six defendant managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.Fraud Report: The manager of multiple medical clinics in Brooklyn and Queens, New York, was found guilty for his role in a nearly $100 million healthcare kickback and money laundering scheme, according the U.S. Department of Justice. Reporting this story will be famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon. Risky Business: Healthcare attorney David Glaser will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Many hospitals are likely in the throes of preparing to implement the Centers for Medicare &amp; Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, including how to reconcile the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The new rule becomes effective Friday, Nov. 29, 2019. “CMS has spent the last two years working on the IMPACT Act, and they are now ready to implement,” reports Mary Beth Pace, vice president of care management at Trinity Health. “Does the CoP resemble anything akin to what you thought they would come out with? It does not to us. Let me reflect on our initial shock, and then our action.” For a field report on how one major health system is preparing for this major new policy, RACmonitor has invited Ms. Pace to be the special guest during the next edition of Monitor Mondays. Other segments to be featured on the broadcast include the following:<ul><li>RAC Report: Healthcare attorney Knicole Emanuel will report on the status of the Medicaid lawsuit filed after more than two dozen plaintiff Virginia behavioral healthcare providers had their managed care contracts terminated by six defendant managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. </li><li>SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey. </li><li>Fraud Report: The manager of multiple medical clinics in Brooklyn and Queens, New York, was found guilty for his role in a nearly $100 million healthcare kickback and money laundering scheme, according the U.S. Department of Justice. Reporting this story will be famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon. </li><li>Risky Business: Healthcare attorney David Glaser will join the broadcast with his trademark segment, in which he reports on problematic issues facing providers. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.</li></ul>

Discharge Planning Conditions of Participation: The IMPACT and Consequences

2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. And RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade.Monitor Monday host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2019 during the next edition of the weekly Internet broadcast:Duane Abbey, PhD; Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Frank Cohen, MPA; William Dombi, Esq.; Knicole Emanuel, Esq.; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; Angela Phillips, PT; Lauren Riplinger, JD; Edward M. Roche, PhD, JD; and Andrew Wachler, Esq.All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. And RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade.Monitor Monday host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2019 during the next edition of the weekly Internet broadcast:Duane Abbey, PhD; Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Frank Cohen, MPA; William Dombi, Esq.; Knicole Emanuel, Esq.; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; Angela Phillips, PT; Lauren Riplinger, JD; Edward M. Roche, PhD, JD; and Andrew Wachler, Esq.All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

2019: Look Out, Look Ahead

2020 ushers in a formidable decade of healthcare regulations and a perilous audit landscape, populated with aggressive auditors who will be aided by artificial intelligence to review and deny claims.Decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and through this new and unchartered decade.Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2020, during the first broadcast of the year for the weekly Internet broadcast, which is celebrating 10 years of live programs. Our line up of panelists includes:Dr. Ronald Hirsch, MD, FACP, CHCQMNancy Beckley, MS, MBA, CHCKnicole Emanuel, Esq.Maureen Testoni, Esq.Stanley Nachimson, MSEdward M. Roche, PhD, JDAndrew Wachler, Esq.Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPAngela M. Phillips, PTWilliam A. Dombi, Esq.Leslie Marsh, RN, BS, MSN, MBA 

2020 ushers in a formidable decade of healthcare regulations and a perilous audit landscape, populated with aggressive auditors who will be aided by artificial intelligence to review and deny claims.Decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and through this new and unchartered decade.Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2020, during the first broadcast of the year for the weekly Internet broadcast, which is celebrating 10 years of live programs. Our line up of panelists includes:<ol><li>Dr. Ronald Hirsch, MD, FACP, CHCQM</li><li>Nancy Beckley, MS, MBA, CHC</li><li>Knicole Emanuel, Esq.</li><li>Maureen Testoni, Esq.</li><li>Stanley Nachimson, MS</li><li>Edward M. Roche, PhD, JD</li><li>Andrew Wachler, Esq.</li><li>Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP</li><li>Angela M. Phillips, PT</li><li>William A. Dombi, Esq.</li><li>Leslie Marsh, RN, BS, MSN, MBA </li></ol>

2020: Look Out, Look Ahead

Like a destructive earthquake, recent news from The Chartis Center for Rural, documenting the accelerated rate of closures among rural hospitals, is sending shock waves through rural communities.As with the Richter scale, the closure of one rural hospital is likely to have an exponential impact on all rural health. And the stark reality is that, as of January 2020, a total of 120 rural health facilities have closed their doors.Leslie Marsh, the chief executive of Lexington Regional Health Center in Lincoln, Neb., returns to Monitor Mondays and reports on precipitous peril for rural hospitals, which is now rising to a national disaster.Other segments featured on the podcast are:RAC Report: Senior healthcare analyst Frank Cohen returns to the broadcast to report on why Recovery Audit Contractors (RACs) can’t be considered unbiased in a court of law.Audit Report:  Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reports Artificial Intelligence (AI) and its impact on compliance and auditing.Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrickson &amp; Bryon, will join the broadcast with his trademark segment Risky Business.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Like a destructive earthquake, recent news from The Chartis Center for Rural, documenting the accelerated rate of closures among rural hospitals, is sending shock waves through rural communities. As with the Richter scale, the closure of one rural hospital is likely to have an exponential impact on all rural health. And the stark reality is that, as of January 2020, a total of 120 rural health facilities have closed their doors. Leslie Marsh, the chief executive of Lexington Regional Health Center in Lincoln, Neb., returns to Monitor Mondays and reports on precipitous peril for rural hospitals, which is now rising to a national disaster. Other segments featured on the podcast are:<ul><li>RAC Report: Senior healthcare analyst Frank Cohen returns to the broadcast to report on why Recovery Audit Contractors (RACs) can’t be considered unbiased in a court of law. </li><li>Audit Report:  Sean M. Weiss, partner and chief compliance officer for DoctorsManagement, reports Artificial Intelligence (AI) and its impact on compliance and auditing. </li><li>Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrickson &amp; Bryon, will join the broadcast with his trademark segment Risky Business. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.</li></ul>

Exclusive: The Plight of Rural Health, Part II

Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare &amp; Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3.Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of care management at Trinity Health, will share how her system approaches the dilemma of sepsis.The broadcast rundown also will include:Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.The Audit Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, returns to report on a new audit by Brown University that reveals the targeting by Medicare Advantage auditors of certain skilled nursing facilities (SNFs).Monday Focus: Rural Health Report: Data from the Centers for Disease Control and Prevention (CDC) reveal another decline in life expectancy. Suicide and drug overdoses continue to be major factors, and suicide rates in rural counties are reported to be nearly double that of urban counties for 2017. Reporting on the state of healthcare in rural America is Leslie Marsh, chief executive officer at Lexington Regional Health Center in Lexington, Neb.Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.Hirsch’s Heroes: Dr. Hirsch will also profile his 2018 “Hirsch’s Heroes” during his popular annual holiday segment.

Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare &amp; Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3.Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of care management at Trinity Health, will share how her system approaches the dilemma of sepsis.The broadcast rundown also will include:<ul><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. </li><li>The Audit Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, returns to report on a new audit by Brown University that reveals the targeting by Medicare Advantage auditors of certain skilled nursing facilities (SNFs). </li><li>Monday Focus: Rural Health Report: Data from the Centers for Disease Control and Prevention (CDC) reveal another decline in life expectancy. Suicide and drug overdoses continue to be major factors, and suicide rates in rural counties are reported to be nearly double that of urban counties for 2017. Reporting on the state of healthcare in rural America is Leslie Marsh, chief executive officer at Lexington Regional Health Center in Lexington, Neb. </li><li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility .</li><li>Hirsch’s Heroes: Dr. Hirsch will also profile his 2018 “Hirsch’s Heroes” during his popular annual holiday segment.</li></ul>

The Dilemma of Sepsis Reporting

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 &amp; Byron  reports on  another example of a potentially troublesome issue that could pose a risk to  your facility.   Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior  healthcare consultant for DoctorsManagement, continues to report on the  vexing issue of Medicare Advantage.   Monday  Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory  Services, makes his Monday Rounds with another installment of his  popular segment. Dr. Hirsch will also present the Monitor Mondays Listener  Survey.  Monitor with us™

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: <ul> <li>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).</li> </ul> <ul> <li>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. </li> </ul> <ul> <li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.</li> </ul> <ul> <li>Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage.</li> </ul> <ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also present the Monitor Mondays Listener Survey.</li> </ul> Monitor with us™

Beware: Emerging New Payer Denial for COPD

U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates.In other news, the Centers for Medicare &amp; Medicaid Services (CMS) released its 2019 Medicare Home Health final rule. Reporting on this major story will be William Dombi, president of the National Association for Home Care and Hospice.The broadcast rundown also will include:Death by Cyber, Part III: RACmonitor investigative reporter and New York attorney Edward Roche will report on how healthcare IT adds to the cost of healthcare, but without offering benefits.Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. In other news, the Centers for Medicare &amp; Medicaid Services (CMS) released its 2019 Medicare Home Health final rule. Reporting on this major story will be William Dombi, president of the National Association for Home Care and Hospice. The broadcast rundown also will include:<ul><li>Death by Cyber, Part III: RACmonitor investigative reporter and New York attorney Edward Roche will report on how healthcare IT adds to the cost of healthcare, but without offering benefits. </li><li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility. </li><li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.</li></ul>

Court Orders HHS to Clear Medicare Appeals Backlog

Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem?Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the American College of Physician Advisors. Dr. Baker has been working with the Centers for Medicare &amp; Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in writing statements noting that these plans have to follow original Medicare regulations for non-contracted facilities. The broadcast rundown also will include:Medicare Advantage Report: A central concern about the capitated payment model used by Medicare Advantage Organizations (MAOs) is the financial incentive for them to inappropriately deny access to services and reimbursements for services rendered in order to increase their profits, according to Knicole Emanuel, partner at the Potomac Law Group, who reports on this developing story.Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron answers listeners’ questions from previous broadcasts on subjects that could be potentially troublesome.“Hello, Are You There?” Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on problems now being created because a Quality Integrity Contractor (QIC) failed to respond to his appeal issues.When Minutes Count: Phones lit up and social media seemed to explode last week when CMS announced it might not allow minutes to count when therapy services are provided by students. The exclusive story was reported on RACmonitor by nationally renowned inpatient rehabilitation facility (IRF) expert Angela Phillips, the president and CEO of Image and Associates. Phillips reports on the details behind the news that is rocking IRF providers’ worlds.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem?Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the American College of Physician Advisors. Dr. Baker has been working with the Centers for Medicare &amp; Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in writing statements noting that these plans have to follow original Medicare regulations for non-contracted facilities. The broadcast rundown also will include:<ul><li>Medicare Advantage Report: A central concern about the capitated payment model used by Medicare Advantage Organizations (MAOs) is the financial incentive for them to inappropriately deny access to services and reimbursements for services rendered in order to increase their profits, according to Knicole Emanuel, partner at the Potomac Law Group, who reports on this developing story. </li><li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron answers listeners’ questions from previous broadcasts on subjects that could be potentially troublesome. </li><li>“Hello, Are You There?” Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on problems now being created because a Quality Integrity Contractor (QIC) failed to respond to his appeal issues. </li><li>When Minutes Count: Phones lit up and social media seemed to explode last week when CMS announced it might not allow minutes to count when therapy services are provided by students. The exclusive story was reported on RACmonitor by nationally renowned inpatient rehabilitation facility (IRF) expert Angela Phillips, the president and CEO of Image and Associates. Phillips reports on the details behind the news that is rocking IRF providers’ worlds. </li><li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.</li></ul>

Medicare Advantage Claim Denials: More Egregious, or More Awareness?

Home health providers are now on alert following an  announcement on Wednesday that the Centers for Medicare and Medicaid Services  (CMS) intends to implement in December its Home Health Pre-Claim Review  demonstration in Illinois, Ohio, North Carolina, Florida, and Texas.In its announcement, CMS issued a notice for a 30-day  public comment period. Reporting this developing story during this edition  of Monitor Mondays will be William A. Dombi, president of the National  Association for Home Care and Hospice.The broadcast rundown also will include: Monday  Focus: The newest compliance issue to gain national attention involves the  T codes. As of Oct. 1, providers are required to document clients who might be  at risk of sex and labor exploitation. Reporting on this story  is nationally  recognized authority on the social determinants of health (SdoH), Ellen  Fink-Samnick. 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  the latest hot topics.  Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron reports on  another example of a potentially troublesome issue that could pose a risk to  your facility. Medicare Payment Report: Are small, independent providers being forced by CMS to increase their  size so that there is enough activity to have the averaged national payments break  even, or be profitable? Author, educator, and consultant Duane Abbey, president  of Abbey and Abbey Consultants, Inc.,  reports on this timely issue. The Hospice Report: Are referrals to hospice frequently the result of misunderstandings of  the purpose of hospice? And why the rush to hospice if death is imminent? Marvin  D. Mitchell, director of case management and social services at San Gorgonio  Memorial Hospital in California,  reports on this critically important  subject. 

Home health providers are now on alert following an announcement on Wednesday that the Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas.In its announcement, CMS issued a notice for a 30-day public comment period. Reporting this developing story during this edition of Monitor Mondays will be William A. Dombi, president of the National Association for Home Care and Hospice.The broadcast rundown also will include:<ul> <li>Monday Focus: The newest compliance issue to gain national attention involves the T codes. As of Oct. 1, providers are required to document clients who might be at risk of sex and labor exploitation. Reporting on this story is nationally recognized authority on the social determinants of health (SdoH), Ellen Fink-Samnick.</li></ul><ul> <li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.</li></ul><ul> <li>Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics. </li></ul><ul> <li>Risky Business: Healthcare attorney David Glaser with Fredrikson &amp; Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.</li></ul><ul> <li>Medicare Payment Report: Are small, independent providers being forced by CMS to increase their size so that there is enough activity to have the averaged national payments break even, or be profitable? Author, educator, and consultant Duane Abbey, president of Abbey and Abbey Consultants, Inc., reports on this timely issue.</li></ul><ul> <li>The Hospice Report: Are referrals to hospice frequently the result of misunderstandings of the purpose of hospice? And why the rush to hospice if death is imminent? Marvin D. Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in California, reports on this critically important subject. </li></ul>

CMS Proposes to Implement Home Health Pre-Claim Review Demonstration

Direct or indirect past affiliation with an individual the Centers for Medicare &amp; Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare.The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, waste, or abuse.Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates. Mr. Wachler also discusses what constitutes an “affiliated entity” and what events must be disclosed.Other segments to be featured on the broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.Court Report: Famed whistleblower attorney Mary Inman reports on Tenet Healthcare’s proposed $66 million False Claims Act settlement. Inman is a partner in the London office of Constantine Cannon.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducted the Monitor Mondays Listener Survey. Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Direct or indirect past affiliation with an individual the Centers for Medicare &amp; Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare. The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, waste, or abuse. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates. Mr. Wachler also discusses what constitutes an “affiliated entity” and what events must be disclosed. Other segments to be featured on the broadcast include the following:<ul><li>RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. </li><li>Court Report: Famed whistleblower attorney Mary Inman reports on Tenet Healthcare’s proposed $66 million False Claims Act settlement. Inman is a partner in the London office of Constantine Cannon. </li><li>Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers. </li><li>SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducted the <a href="https://www.racmonitor.com/monitor-mondays-podcasts/monitor-mondays-listener-survey" rel="nofollow" target="_blank">Monitor Mondays Listener Survey</a>. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.</li></ul>

Known by the Company You Keep: Disclosures of Affiliations

Seema Verma

Seema Verma, the Centers for Medicare &amp; Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on the volume of claims?  Reporting this developing story during the next edition of Monitor Monday will be John K. Hall, MD, founder of The Aegis Firm. Other segments to appear during the live broadcast include:RAC Report: Healthcare attorney Knicole Emanuel will return to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.Monday Focus: Several different trends are simultaneously affecting physician payment even delimiting consideration to the Medicare program.  Reporting on these trends and their impact on physician reimbursement and compliance requirements will the author, educator and consultant Duane Abbey, president of Abbey &amp; Abbey Consultants, Inc.Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment. 

Seema Verma, the Centers for Medicare &amp; Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on the volume of claims?  Reporting this developing story during the next edition of Monitor Monday will be John K. Hall, MD, founder of The Aegis Firm. Other segments to appear during the live broadcast include:<ul><li>RAC Report: Healthcare attorney Knicole Emanuel will return to the broadcast to report on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group. </li><li>SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on social determinants of health (SdoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey. </li><li>Monday Focus: Several different trends are simultaneously affecting physician payment even delimiting consideration to the Medicare program.  Reporting on these trends and their impact on physician reimbursement and compliance requirements will the author, educator and consultant Duane Abbey, president of Abbey &amp; Abbey Consultants, Inc. </li><li>Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers. </li><li>Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment. </li></ul>

The Seema Verma Blog Post That’s Making Providers Anxious

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