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Monitor MondaysHealthcare News Roundup: Special 60-Minute EditionWhile much of today’s healthcare news is righty focused on the efforts to stave off the global coronavirus pandemic, there is other news to report – and Monitor Mondays will have a complete wrap-up on all of it during the next edition of the weekly Internet radio broadcast, while also looking ahead.And given the tendency of the Centers for Medicare & Medicaid Services (CMS) to issue waivers and guidance with a unique style of ambiguity, a great deal of confusion also continues to come from hospitals and health systems in their efforts to remain compliant – while at the sa...2020-05-1256 minMonitor Mondays340B Dodges Another BulletA federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program. U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association v. Alex M. Azar, HHS Secretary, ordering HHS back to the drawing board and warning it to act with haste to make a correction. Reporting our lead story during this edition of M...2019-05-2029 minMonitor MondaysInpatient versus Outpatient: Status of Psych Patients in the EDConfusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and frustration.Reporting our lead story during this edition of Monitor Mondays is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States in...2019-05-1329 minMonitor MondaysNew Proposal for Dual-Eligibility Beneficiaries: Good Intentions or Cost Cutting?The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid.More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. Could the CMS initiative suggest cost-cutting, administrative burden reductions, or true innovation? RACmonitor national correspondent J. Paul Spencer, a senior health consultant for DoctorsManagement, reports our...2019-05-0629 minMonitor MondaysCongressional Action on Surprise Balance BillingNews reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing.Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albright will also report on drug rebate discussions and how those discussions are being impacted by broader reform proposals such as Patient Protection and Affordable Care Act (PPACA) stabilization, outright repeal, and Medicare-for-all.Other segments to appear on the broadcast include:2019-04-2930 minMonitor MondaysECAPE: Revealing the New Backlog Buster at OMHANew from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA. Other segments to appear on the broadcast include:Monday Focus: Healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will provide context and perspective to the ECAPE system at the OMHA.2019-04-2230 minMonitor MondaysCMS and Prescription Drug Prices, Part II: 340B State of the UnionIn the final installment of a two-part series on prescription drug prices, during this edition of Monitor Mondays we will report on the latest initiative on a new “war on drugs” – the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered under the 340B federal drug program. Reporting on this development will be Maureen Testoni, Esq., president and CEO for 340B Health. Other segments to appear on the broadcast include:Monda...2019-04-0130 minMonitor MondaysCMS and Prescription Drug Prices, Part I: 2019 Drug Spending DashboardsIn the first portion of a two-part series on prescription drug prices, during this edition of Monitor Mondays we report on the Centers for Medicare & Medicaid Services (CMS) Drug Spending Dashboards with data for 2017.First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousands of more drugs across Medicare Parts B and D and Medicaid. Reporting Part I of the series will be Timothy Powell, a regulatory expert and a RACmonitor national correspondent. During Part II, scheduled for A...2019-03-2528 minMonitor MondaysSingle-Payer Healthcare for New Yorkers: An Option on the TableCould the Empire State be among the first to introduce a single-payer healthcare system?The latest news coming from Albany would seem to indicate that; now that both state legislative branches are under control of the Democrats, such an option is likely viable. Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no access to healthcare.Reporting our lead story during this episode of Monitor Mondays will be Dennis Jones, a New Yorker and the administrator of patient financial services at...2019-03-1829 minMonitor MondaysChallenging the Ambiguity of an Agency’s RegulationsThe preponderance of ambiguously worded regulations from federal agencies – think the Centers for Medicare & Medicaid Services (CMS) – will be at the center of a major legal challenge coming March 26 to the nation’s highest court, and you’ll hear the details here during this edition of Monitor Mondays.That’s when Jennifer Gustafson will report our lead story, focusing on the U.S. Supreme Court (SCOTUS) taking up the case of Kisor vs. Wilkie (U.S. Marine James Kisor vs. the U.S. Department of Veterans Affairs).The dispute is over denied Veterans Affairs (VA) benefits...2019-03-0430 minMonitor MondaysIs 340B at Risk?“It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place," President Donald Trump told members of Congress during his State of the Union address on Wednesday. "This is wrong, unfair, and together we will stop it. We will stop it fast," the President warned. During his address, the President also pledged to end the HIV epidemic in the nation.Both issues will be discussed during this edition of Monitor Mondays, when Maureen Testoni, president and CEO for 340B Health, returns to the br...2019-02-1131 minMonitor MondaysOut of Town by Sundown: “Must Be Done by End of Business Day.” Payer-Provider PressureAre you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied? Are you being told you cannot have a peer-to-peer session because your request was considered late? Are you hearing that you must have everything — “pre-denial” or “pre-auth” — done within 72 hours of notification, only they typically wait until they only have three hours left? During this edition of Monitor Mondays, listen and learn what Val Kraus and his team at one major Midwest health system a...2019-02-0429 minMonitor MondaysTKA 2.0: CMS Updates Total Knee Arthroplasty, AgainSeeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & 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...2019-01-2830 minMonitor Mondays2019: Look Out, Look Ahead2019 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...2019-01-1458 minMonitor MondaysDismissal Expected in Providence Health FCA LawsuitDuring this edition of Monitor Mondays, nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States declined to intervene in the case, and the allegations are likely to be dropped on Jan. 14, 2019.The broadcast rundown also will include:Monday Focus: Lawmakers in Michigan have approved permanent medical marijuana licensing rules, including a provision to al...2018-12-0328 minMonitor MondaysMedicare Advantage Claim Denials: More Egregious, or More Awareness?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 & Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in wr...2018-11-2630 minMonitor MondaysCourt Orders HHS to Clear Medicare Appeals BacklogU.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 & 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...2018-11-1230 minMonitor MondaysProvider-Based Clinics: Major Changes Coming SoonThe Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November. The proposed changes are expected to impact compliance and reimbursement. Reporting this developing story during this edition of Monitor Mondays is author, educator, and consultant Duane Abbey, who will discuss how the proposed changes are likely to impact Medicare providers.The broadcast rundown also will include:False Claims Act: Famed whistleblower attorney Mary A. Inman, a partner at Constantine Cannon’s London office, reports that DaVita Medical Group has agreed to pay $270 million to CM...2018-10-2930 minMonitor MondaysCMS Proposes Changes to Medicare Shared Savings Program: Probing the Impact on ProvidersThe Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program. Reporting this developing story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, who will discuss how the proposed changes are likely to impact Medicare providers.The broadcast rundown also will include:TPE: Targeted Probe and Educate Audits continue to generate confusion and concern. Returning to report on this developing story is healthcare attorney Andrew Wachler who has a follow-up to his reporting last Monday on Monitor Monday.Death by Cyber...2018-10-2230 minMonitor MondaysTargeted Probe-and-Educate Audits: Three Strikes and You’re OutTargeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to a Recovery Audit Contractor (RAC), suspension of Medicare payments, or even revocation of Medicare billing privileges.Reporting our lead story during this edition of Monitor Mond...2018-10-1530 minMonitor MondaysCMS Proposes to Implement Home Health Pre-Claim Review DemonstrationHome 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...2018-10-0132 minMonitor MondaysCMS Proposed Rule Intended to Alleviate Regulatory Burdens: Will it Work?As expected, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group. The broadcast rundown also will include: Monday Focus: Giant healthcare insurer UnitedHealth is back in the news, this time for being named in a lawsuit involving Medicare Advantage. Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports t...2018-09-2429 minMonitor MondaysCompliance During Adversity: Hurricane FlorenceAs bands of rain and wind from Hurricane Florence are lashing North Carolina, hospitals, health systems, and physician practices are preparing for what is being called the “storm of a lifetime.” Earlier this week, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that Medicaid and Medicare beneficiaries have access to medical care despite the storm, according to a posting on the HHS website. HHS also said it has positioned about 230 medical personnel in North Carolina and Maryland to help comm...2018-09-1730 minMonitor MondaysLast Chance to Take a Stand: Comment Period for Proposed E&M Changes Ends Few proposals from the Centers for Medicare and Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E and M) reimbursement changes in the 2019 Medicare Physician Fee Schedule. The outrage has been intense over the plan 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...2018-09-1030 minMonitor MondaysAnatomy of an Alleged False Claims Act Violation: The Providence Health & Services LawsuitA 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...2018-08-2730 minMonitor MondaysControversy Continues to Swirl Around Proposed E&M Changes The Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes in the recently posted 2019 Medicare Physician Fee Schedule continue to generate controversy. The controversy centers around 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. Reportin...2018-08-1330 minMonitor MondaysBeware: Emerging New Payer Denial for COPDThere’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 Recov...2018-07-3029 minMonitor MondaysCourt Ruling Creates Major Setback for 340B Drug Program
The 340B drug pricing program suffered a major setback Tuesday, when the U.S. Court of Appeals dismissed a key American Hospital Association (AHA) lawsuit to block $1.6 billion in cuts.
The three-judge panel ruled that the lower court had properly dismissed AHA's case because the association failed to fulfill the legal prerequisites to judicial review. Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner at the Potomac Law Group.
The broadcast rundown also will include:
False Claims Act Report: Nationally recognized whistleblower attorney Mary...2018-07-2330 minMonitor MondaysThe Readmissions Quagmire: Medicaid Work Requirements Pose Audit Risks
The state of Kentucky has introduced Medicaid work requirements. And the trend seems to be proceeding fast and furiously in other states looking to cut health and behavioral health benefits of Medicaid enrollees, with officials saying the costs can’t be met otherwise. Kentucky eliminated vision and dental benefits to 500,000 Medicaid enrollees within 36 hours of the federal decision.
Imagine the impact to the readmissions quagmire if benefits continue to be cut for the most vulnerable and disenfranchised members of society, or those most impacted by the social determinants of health (SdoH).
These costs are al...2018-07-0930 minMonitor MondaysAppeal Relief Has Arrived: OMHA Implements Expansion to Settlement Conference Facilitation
The Office of Medicare Hearings and Appeals (OMHA) has implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process. The process provides appellants and the Centers for Medicare & Medicaid Services (CMS) an opportunity to discuss a mutually agreeable resolution for claims appealed to the administrative law judge (ALJ) or Medicare Appeals Council (Council) levels of appeal.
Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Erin Diesel Roumayah with Wachler & Associates.
The broadcast rundown also will include:
Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president...2018-06-2530 minMonitor MondaysPain Points of Pain Management Services The National Institutes of Health (NIH)is expected to receive an additional $500 million to spend annually on pain management and opioid use. On Tuesday, the agency published details as to how the infusion of additional money will be used as part of a program titled “Helping to End Addiction Long Term (HEAL)."
Earlier this week, the Centers for Medicare & Medicaid Services (CMS) approved facet joint injections for auditing, warning that auditors will review medical documentation to determine that services were medically reasonable and necessary.
Reporting on this latest development will be American Medical Association (AMA) au...2018-06-1830 minMonitor MondaysTotal Knee Replacement: The Intersection of Functionality and Care LevelsThe subject of total knee replacement (TKR) continues to reverberate. In this edition of Monitor Monday, Lori O’Hara, the lead of the ADR, appeals and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, will offer the perspective of a long-term care provider. Her position is that a TKR patient either needs medical oversight or they do not. The question of the proper environment, O’Hara answered by finding where the patient’s medical and functional presentation intersects the lowest level of safe care.
The broadcast rundown also will include:
...2018-05-2130 minMonitor MondaysLatest News: Feds Delay 340B Enforcement RulesThe Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally issued by the outgoing Obama Administration in January 2017. It was formally published on Monday. National Correspondent Timothy Powell reported our lead story on this episode of Monitor Mondays on 340B.
The broadcast rundown also will include:
Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reported on a whistleblower case that is at...2018-05-1429 minMonitor MondaysIPPS Proposed Rule: Major Changes for IRF ProvidersThe dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear to be experiencing relief not typically associated with other proposed rule changes. For them, the proposals from CMS for FY 2019 reflect some positive changes related to reductions in paperwork and, if finalized, they will provide some easing of the workload. One of the nation’s most respected authorities on IRF provider issues, Angela Phillips, president and chief executive officer for Images & Associates, repo...2018-05-0728 minMonitor MondaysAuditing Non-physician PractitionersCould non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors? While physicians reportedly represent nearly a million targets for audits, add in another couple of hundred thousand nurse practitioners (NPs) and physician assistants (PAs) and target acquisition becomes that much richer. And in their minds, so do the auditors, according to Frank Cohen, director of analytics and business intelligence for DoctorsManagement, who reports on his latest findings during this episode.
The episode rundown also includes:
Monday Rounds: Ronald Hirsch, MD, vice president of R1 P...2018-04-2330 minMonitor MondaysAHA Ordered to Fix the Medicare Appeal BacklogJudge James E. Boasberg of the United States District Court for the District of Columbia has ordered the American Hospital Association (AHA) to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the Administrative Law Judge (ALJ) level.
Reporting this developing story is healthcare attorney Andrew Wachler, Esq., managing partner at Wachler and Associates.
The episode rundown also includes:
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...2018-04-0930 minMonitor MondaysTelemedicine: Significant Expansion, Followed by a Return to NormalcyTelemedicine, considered to be an electronic lifeline for rural healthcare, is a rapidly growing sector of health care in the United States that has recently gone through a significant expansion.
Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac's report on Telemedicine, is attorney Dale C. Van Demark, a partner at McDermott Will & Emery in Washington, D.C.
The episode rundown also includes:
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of...2018-04-0229 minMonitor MondaysHow to Predict the Likelihood of an AuditDiving deep into the datasphere, senior healthcare analyst Frank Cohen comes up for air in order to report on a new approach he and his team of data experts have developed to predict the likelihood of an audit. While he claims that his team is not yet predicting billing errors, he does report that many of the variables being used to do so can also be used to forecast audits. During this episode Cohen, director of analytics and business intelligence for DoctorsManagement, reports on his latest findings, which could help you and your facility ward off an audit.
2018-03-2630 minMonitor MondaysAnthem BlueCross BlueShield and UnitedHealthcare: New Worries for Patients and ProvidersPatients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful of not having their visits covered. Former ED physician-turned healthcare consultant Erica Remer, herself an Ohioan, reports on this developing story.
Another headline grabbing story is the reported lawsuit filed by Envision Healthcare against UnitedHealthcare (UHC). Envision is using the giant insurer alleging the UHC "unilaterally" lowered payments of Envision's contracted physicians, according to Axios. Healthcare attorney Mary Inman...2018-03-1928 minMonitor MondaysMedicare and Medicaid RAC Audits: How Auditors Get It WrongRACmonitor was founded in 2008 to provide news and information for healthcare providers on the emergence of the government’s Recovery Audit Contractor (RAC) program. From a Centers for Medicare & Medicaid Services (CMS) demonstration in that year, and continuing to the national rollout in 2010 (coincidentally, the year of Monitor Mondays’ national debut), we have been reporting on activities not only of the RACs, but also the Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), and the Quality Improvement Organizations (QIOs).
But why, after nearly 10 years, do these auditors still tend to get auditing wrong? Providing insight into this...2018-03-1230 minMonitor MondaysTime to Junk the Peer-to-Peer Process?"The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians," reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. "These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient."
During this episode of Monitor Mondays Dr. Hopkins makes the case for abandoning your P2P process if the results are not satisfactory. Might the pressure of P2Ps even be contributing...2018-02-2630 minMonitor MondaysTotal Knee or Total Consternation?Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility?
Mary Beth Pace, vice president of care management at Trinity Health and the special guest on this edition of Monitor Mondays, frames the conundrum as a hypothetical patient/caregiver conversation: "we are going to do major surgery on you, but we are not sure if we will keep you after surgery – and oh, by the way, there will be...2018-02-1930 minMonitor MondaysEMR and RAC Audits: Who Takes the Hit? Part IIWho bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor Mondays, when whistleblower attorney Mary Inman reports on an ongoing qui tam action under the federal False Claims Act through which a relator alleges that Bon Secours Health System, Inc. fraudulently billed Medicare and Medicaid millions of dollars. Inman also reports on other current whistleblower cases.
The episode rundown also includes:
Monday Rounds: Ronald Hirsch, MD, vi...2018-02-1230 minMonitor MondaysEMR and RAC Audits: Who Takes the Hit?On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records?
Many of these electronic records are self-populated. So, what happens if you undergo a Recovery Audit Contractor (RAC) audit and are accused of wrongdoing? Offering insight into this issue during the next edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, who will be the broadcast's special guest.
The episode rundown also includes:
...2018-02-0531 minMonitor MondaysHEDIS Reviews: How to Avoid Payer AbrasionHealthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called Star Ratings, which are ultimately published on the Centers for Medicare & Medicaid Services (CMS) website. Explaining the rating systems as well as offering best practices to minimize payer abrasion during this episode of Monitor Mondays is special guest Greg Ford with MRO.
The episode rundown also...2018-01-2926 minMonitor MondaysMedicare Advantage: What’s the Advantage?“We have been slammed with Medicare Advantage DRG audits,” wrote Sandra from Indiana during last week’s Monitor Mondays broadcast. We asked RACmonitor national correspondent J. Paul Spencer with DoctorsManagement to investigate this issue for this week's episode. Will there be more of these audits? Do these represent low-hanging fruit for auditors? Stay tuned.
The episode rundown also includes:
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will file another report on the controversial total knee replacement (TKR) issues that continues to confound physicians and patients.
Hot Topics...2018-01-2229 min