Shows
Stark IntegrityMedicaid Reimbursement Litigation Is Possible: A Discussion with Knicole Emanuel, Partner at Nelson MullinsSend us a text You don’t have to accept what is given to you. In this episode, Captain Integrity Bob Wade dives into Medicaid reimbursement litigation with Knicole Emanuel, Partner at Nelson Mullins. Hear why litigation is an option to fight low Medicaid rates, why you don’t need to accept the reimbursement rates presented, how medical equity works, the David vs. Goliath case Knicole worked on, and some examples in terms of children’s dental needs. Learn more at CaptainIntegrity.com2025-03-0517 minStark IntegrityOverpayment Notices, Mistakes, and Appeal Process: A Conversation with Knicole Emanuel, Partner at Nelson MullinsSend us a textOh no - the dreaded overpayments. In this episode, Captain Integrity Bob Wade explores overpayment notices, mistakes, and the appeal process with Knicole Emanuel, Partner at Nelson Mullins. Hear why tentative notices of overpayments are scary but defensible, why you should know your right to appeal, the potential changes coming that may be in the providers’ best interest, why you should have some legal assistance through this process, and the alphabet soup of acronyms. Learn more at CaptainIntegrity.com2024-10-0921 min
NM Talks HealthcareNavigating Medicare and Medicaid Regulatory Audits The Devil You KnowIn this episode, Nelson Mullins partner Knicole Emanuel and senior associate Melissa Scott analyze the framework of Medicare and Medicaid regulatory audits of healthcare providers by shedding light on the relationship between the Medicare and Medicaid Integrity Programs and the types of contractors driving the force of compliance investigations. Emanuel and Scott also provide an overview of the audit process and strategies for providers to manage compliance-related risks and defend against unfavorable audit decisions.2024-06-1418 min
Monitor MondaysPrepare Now Audit Frenzy Amid Hospitals Executing Crisis Standards of CareAs healthcare attorney Knicole Emanuel recently reported here on RACmonitor, in 2022 providers can expect a “frenzy” of audits – although it seems to be happening already now, as some hospitals are executing crisis standards of care while coping with an influx of COVID-19 patients (namely, unvaccinated patients who have contracted the deadly Delta variant).The result is that many hospitals are on the brink of disaster, their resources stretched to the breaking point. Joining the next upcoming broadcast of Monitor Mondays will be John Zelem, MD, former general surgeon-turned-healthcare consultant. Dr. Zelem will report the lead story on the broadca...2021-09-2729 minMonitor MondaysRampant RACs: Auditor Industry Profiting at Providers’ ExpenseSPECIAL GUESTEdward Roche, JD, PhDDirector, Scientific Intelligence, Barraclough NY LLCALSO FEATURINGMatthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP;David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQRACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant abuse directed at healthcare providers by overzealous (and, in some cases, incompetent) auditors.Relying on scant evidence of actual fraud, the auditors, working in what Roche describes as a giant industry, deny claims while ignoring more the...2021-07-1930 min
That One CaseConverting Blog Posts to Clients: Knicole C. Emanuel, PractUS LLP, MedicaidlawNC.comIn this episode of That One Case, we talk with Knicole C. Emanuel, partner at PractUS, LLP. Knicole is a health care litigator with a focus on healthcare regulatory compliance, administrative law and regulatory law. Knicole has a particular interest in Medicare and Medicaid litigation, which she has channelled into her blog medicaidlawnc.com, offering advice to providers and attorneys alike.On today's show, Knicole tells us about how her blog went from a side project to her main source of business and how her posts lead to her representing nearly all of the behavioral healthcare providers...2021-03-1010 minMonitor MondaysRegulatory News Roundup: Major Changes Underway by the New AdministrationChanges to the nation’s Medicaid program, which reportedly covers some 70 million people, are expected soon. According to news reports, among the looming changes is the elimination of the work requirement for Medicaid recipients.This will mark the featured topic during the next live edition of Monitor Mondays, when healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report on this change and others that will affect providers.Other segments to be featured during the live broadcast include the following:Social Determinants of Health: Ellen Fink-Samnick, a2021-03-0130 minMonitor MondaysCOVID-19 News Update – The Mask MandateEven as the nation continues to struggle with the coronavirus pandemic, President Joe Biden, who took office Thursday as the 46th President, signed executive orders mandating that masks be worn on federal property and for interstate travel on trains, transit systems, and airlines – this being part of the President’s agenda for the first 100 days in office. Meanwhile, shortages of the COVID-19 vaccine are being reported throughout the country, most notably in the Big Apple, where New York City Mayor Bill de Blasio reportedly said the city would exhaust its vaccine supply this week.Reporting our lead stor...2021-01-2530 minMonitor MondaysIncreases in Physician Payments Also Means Greater RecoupmentMost physicians are expected to see in an increase in payments from Medicare, thanks to the latest COVID-19 relief bill. But with good news always comes some caution.First of all, the more that is paid, the more can be recouped during an audit. And with respect to provider compensation models that rely on relative value units (RVUs), it is possible that the increase in work RVUs may exceed the increase in the total RVUs – meaning that a provider may make more than what is proportional to overall practice revenue. This could have implications with respect to fa...2021-01-1830 minMonitor Mondays2021: Look Out, Look AheadWith the calamitous year of 2020 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future of America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system.With so many major changes expected to take place in 2021, 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 throughout a new year that has...2021-01-1158 minMonitor MondaysRegulatory News Roundup: A Special 60-Minute Open Door ForumAmid the chaos created by the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) released two major final rules this week: the 2021 Physician Fee Schedule and the Outpatient Prospective Payment System (OPPS), with the latter having been widely anticipated. Both final rules portend significant new regulatory changes for providers, patients, and payors. Given the gravity of these new changes, the next upcoming Monitor Mondays broadcast will encompass a special live open door forum to answer questions from listeners.Segments to be featured during the live broadcast include the following:Court Report: Famed whistleblower...2020-12-0759 minMonitor Mondays$6.38 Million Medicare Advantage Whistleblower SettlementA whistleblower recently exposed an alleged risk-adjustment scheme that was apparently designed to artificially inflate reimbursement provided under Medicare Part C, aka Medicare Advantage (MA).The accompanying lawsuit alleged that GHC hired an outside vendor to review and “improve” its risk adjustment scores. According to the whistleblower, GHC submitted tReporting our lead story on this matter during the next live edition of Monitor Mondays will be Max Voldman, JD, an associate of Constantine Cannon.Other segments to be featured during the live broadcast include the following:Special Report: Bereavement: Elle...2020-11-3029 minMonitor MondaysTriaging Denials: Emphasize Preparation, Don’t PanicThere has recently been, as some might suggest, the luxury of taking a brief hiatus from medical record audits.But that was then, and this is now.Because now is the time to prepare, assess timeframes and provider requirements, and ensure that a proper compliance plan is in place. Certainly, audits are a growing source of concern, but there is no need for panic when adequately prepared, as you’ll learn from Susan Gatehouse, founder and CEO for Axea Solutions, who will be the special guest during the next live edition of Monitor Mondays.2020-11-1630 minMonitor MondaysAvoiding a Major Healthcare Crisis: The Need to Bring Back Post-Acute WaiversThe coronavirus winter surge is quickly approaching, and at a time when the United States is experiencing record numbers of daily positive COVID-19 tests, with corresponding increases in hospitalizations expected to follow. What the country needs now is for payers – both governmental and commercial – to reinstitute post-acute authorization waivers, since such waivers have largely expired. Currently, UnitedHealthcare, Aetna, and Anthem have no post-acute authorization waivers in place for any patients, including COVID-19 patients.Without these waivers, hospitals must again go through the authorization process for post-acute stays. Reporting our lead story during the next edition of Monitor Mond...2020-11-0930 minMonitor MondaysCivil Monetary Penalties for Paying Ransomware DemandsThe United States Department of the Treasury’s Office of Foreign Assets Control (OFAC) recently issued an advisory on potential sanction risks for facilitating ransomware payments. It warned that entities, including hospitals, paying off ransomware demands might be subject to civil monetary penalties under the International Emergency Economic Powers Act (IEEPA).This action places hospitals in danger of being guilty of such violations, even when they are the victim of a crime. Reporting our lead story during this edition of Monitor Mondays is RACmonitor investigative reporter Ed Roche, who has been reporting on ransomware for RACmonitor since 2017.2020-11-0232 minMonitor MondaysBeware of Audit Hot Spots Highlighted by the CARES ActProviders that received payments from the federal Provider Relief Fund will be required to file reports demonstrating their compliance with the terms and conditions of those payments.Reporting on this, our lead story during the next live edition of Monitor Mondays, will be healthcare attorney Andrew Wachler, managing partner of Wachler & Associates. Mr. Wachler will report on anticipated “hot spots” in the auditing of the use of these payments, including healthcare-related costs and lost revenue attributable to the coronavirus and expenses that have been reimbursed from other sources.Other segments to be featured during the live broa...2020-10-2635 minMonitor MondaysStopping the Bleeding: More Cuts Proposed for 340BMore payment cuts are being proposed by the Centers for Medicare & Medicaid Services (CMS) for next year, a move sure to impact the many hospitals participating in the 340B drug discount program, as described in the 2021 Medicare Outpatient Prospective Payment System (OPPS) Proposed Rule.Such proposed cuts are expected to reduce Medicare Part B drug payments to levels lower than in 2018, when the last round of cuts were made. Reporting our lead story during the next edition of Monitor Mondays will be Maureen Testoni, CEO for 340B Health. Also participating in the broadcast will be ICD10monitor...2020-10-1953 minMonitor MondaysHas Focus on Length of Stay Run its Course?The venerable topic of length of stay (LOS) has recently been generating buzz among healthcare professionals – so much so that we asked Stefani Daniels, founder and managing partner of Phoenix Management, to return to the weekly Monitor Mondays broadcast with an update, noting that the use of LOS has apparently declined.But is it still a valuable metric? And how might LOS be used today? This question becomes even more relevant as hospitals work to improve efficiencies, reduce costs, and perhaps, decrease LOS.Other segments featured during this episode include:RAC Report: He...2020-10-1229 minMonitor MondaysTelehealth Fraud Bust: Fed Takedown Nets $6 Billion, 345 DefendantsThe U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently closed in on more than 345 defendants charged with participating in scams involving more than $6 billion in alleged losses to federal healthcare programs.The takedown occurred in September, according to the OIG. Of that amount, approximately $4.5 billion was associated with telemedicine schemes. The action by the feds puts a spotlight on the growing use of telehealth as a consequence of the ongoing coronavirus pandemic.Reporting our lead story during this edition of Monitor Mondays is John K. Hall, an attorney...2020-10-0532 minMonitor MondaysCMS Orders Medicare Advantage Organizations to Cease “Pseudo Denials” to Non-contracted ProvidersThe Centers for Medicare & Medicaid Services (CMS) has moved to stop Medicare Advantage Organization (MAO)-hired subcontractors from issuing “pseudo-denials” that require pseudo-appeals before the MAO considers the denial formalized.The practice is reported to be extremely widespread and used against non-contracted providers: small, often rural hospitals that tend to be more vulnerable to these tactics.Reporting our lead story during the next live edition of Monitor Mondays will be Lisa Banker, MD, formerly chief medical advisor for revenue integrity at CarolinaEast Health System. Dr. Banker led the effort to convince CMS of the need to i...2020-09-2830 minMonitor MondaysAn Ominous Forecast: Auditors are Ramping Up ActivitiesThe recent announcement by the Centers for Medicare & Medicaid Services (CMS) that it will be “ramping up” audits are quickly becoming a reality for providers across the country. Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), and Unified Program Integrity Contractor (UPIC) auditors are going full steam ahead, using data and analytics to assess overpayments via automated reviews – and new language in UPIC letters paints an ominous picture for providers they deem non-compliant.Reporting the lead story during this edition of Monitor Mondays is Sean M. Weiss of DoctorsManagement, who addresses these issues...2020-09-2133 minMonitor MondaysThe RVU Conundrum: Expect Declines in Operating IncomeThe Centers for Medicare & Medicaid Services (CMS) will reimburse a greater number of relative value units (RVUs) associated with office-based evaluation and management (E&M) visits, the agency announced recently.In order to achieve budget neutrality, CMS will reduce the payment per RVU. With this change, CMS is allocating a larger proportion of its total spending to office-based physicians, at the expense of surgeons and hospital-based physicians.Here’s the rub: organizations that utilize RVUs in their physician compensation arrangements and continue to pay the same 2020 rates per RVU on the increased number of 2021 RVUs wi...2020-09-1434 minMonitor MondaysEXCLUSIVE: The Healthcare Algorithms Arms Race is Heating UpUnlike the Cold War arms race between the then-Soviet Union and the United States, today’s arms race is being fought before computer monitors, and in the deep corners of computer laboratories. And the weapon of choice: algorithms.This fierce fighting is taking place between auditors and providers, and the stakes are high: money. Lots of it.No stranger to chronicling the former Cold War arms race, Edward Roche, RACmonitor’s investigative reporter, returns to the Monitor Mondays broadcast to report on how algorithms created by payers tend to foster a camouflage of mediocrity for prov...2020-08-3130 minMonitor MondaysBig Pharma versus 340BIn recent weeks, several major pharmaceutical manufacturers have taken actions that could lead to narrowing the 340B Drug Pricing Program, which provides outpatient drugs to safety-net hospitals, health centers, and clinics at discount prices. The savings are invested in care for patients with low incomes, living in rural communities.The actions by Eli Lilly, Merck, and Sanofi are being challenged by a coalition of safety-net providers, including 340B Health, which represents more than 1,400 340B hospitals. Reporting our lead story during this edition of Monitor Mondays is Maureen Testoni, president and CEO of 340B Health, who will discuss...2020-08-2429 minMonitor MondaysCalifornia Whistleblower Claim Yields $24 Million Abbvie SettlementCalifornia is one of two states in the country that rewards whistleblowers for bringing forward information about private insurance fraud. A recent $24 million settlement with pharmaceutical giant Abbvie over the marketing of the company’s blockbuster drug, Humira, demonstrates the law’s effectiveness.The settlement agreement was reached last week following allegations that the company violated California’s Insurance Frauds Prevention Act. Abbvie agreed to the settlement despite continuing to deny any wrongdoing.On the next live edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will provid...2020-08-1730 minMonitor MondaysExclusive 60-Minute Broadcast: COVID-19 RulesThe omnipresent coronavirus pandemic continues to upend lives, from mundane occasions like grocery shopping to long-planned space exploration missions. The pandemic is manifesting itself from the halls of Congress to the cubicles at Centers for Medicare & Medicaid Services (CMS) headquarters, to classrooms, theatres, homes, and places of worship, among other venues.On the next live edition of Monitor Mondays, we will explore the impact of the coronavirus on audits and auditing, proposed rules, guidance, and waivers.Joining the broadcast to report on anticipated pandemic-related audits will be Dr. John K. Hall, founder of The Aegis...2020-08-1056 minMonitor MondaysThe Virus and the Audits: A Special 60-Minute News RoundupTwo major storylines are discussed during this edition of Monitor Mondays, with the exclusive 60-minute broadcast to focus on the raging coronavirus pandemic and the imminent auditing of Medicare and Medicaid claims scheduled to begin Aug. 3, as directed by the Centers for Medicare & Medicaid Services (CMS).Joining the broadcast to report on the coronavirus will be Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Alpert Medical School of Brown University. Offering an update on the imminent audits of Medicare and Medicaid claims will be healthcare attorney Andrew Wachler, managing partner of Wachler and...2020-07-2857 minMonitor MondaysBagnall to Alexander- finally over? An assessment of Alexander V Azar on healthcareCould Alexander VS. Azar really be over? This week's Monitor Mondays episode we've called upon or resident healthcare attorneys Knicole Emanuel Esq., David Glaser Esq. and our guest host John K. Hall MD, JD to dissect and assess the complicated case.The case has been disorganized since the beginning, possibly leaving more questions than answers. This Monitor Mondays round table will analyze procedural aspects of the case and what it could potentially mean for providers, analyze where the decision has risk for providers, and provide guidance of how providers should respond in the future.Other...2020-07-2033 minMonitor MondaysCash and Lavish Goodies to Bribe Physicians to Prescribe Novartis Drugs: Anatomy of FCA AllegationsLast week, pharmaceutical giant Novartis paid $51 million to settle a Massachusetts suit about patient copay waivers. The DOJ press release notes that this is the 14th settlement of this kind to come from the Boston area. In related news, the Government brought a suit against Regeneron alleging that the company had a scheme of very well calculated charitable giving that steered patients to its macular degeneration drug, which costs $1,850 per dose, and away from a competitor’s drug, which costs $55 per dose.We are joined this week by Mary Inman, Esq. who has the latest on the No...2020-07-1331 minMonitor MondaysA Troubling Cornucopia of COVID-Related FraudThe advent of the COVID-19 pandemic in the United States has generated nearly 2.5 million positive diagnoses, nearly 125,000 deaths – and dozens upon dozens of instances of modern-day snake-oil salesmen seeking to profit amid all of the chaos.Presenting the lead story during this edition of Monitor Mondays is Edward M. Roche, who will describe the various ways in which federal authorities are looking to stamp out the opportunistic fraudsters.Other segments to be featured in the podcast:RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Mo...2020-06-2931 minMonitor MondaysRespiratory Failure Denials could become more common, get ready for post-pandemic denialsDon't let your guard down, post COVID-19 respiratory failure denials are on the horizon. Andrea Taylor from Enjoin reports why we aren't seeing denials yet and tips for appeals and waivers.Other segments featured during the podcast include:RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report.SDoH Report: Ellen Fink-Samnick reports on the National Health and Nutrition Examination Survey. Ellen will also conduct the Monitor Mondays Listener Survey.Legislative Update: Matthew Albright reports on the status of key healthcare legislation and the...2020-06-2228 minMonitor MondaysExclusive: Post-Pandemic COVID-19 Audits and DenialsWelcome to the new normal. You and your team continue to be challenged by consequences of the coronavirus pandemic, dealing with PPE shortages, along with confusing and oftentimes contradictory guidance from the Centers for Medicare & Medicaid Services (CMS).And now, we look onward – toward the audit horizon, and looming denials for COVID-related care. You need to be aware of ongoing payor expectations and potential risk areas for denials. Returning to Monitor Mondays to report our lead story during this edition of the weekly Internet radio broadcast will be Dr. John K. Hall, founder of The Aegis Firm, a...2020-06-1529 minMonitor MondaysExclusive: The Intersection of COVID-19 and Inpatient Rehabilitation FacilitiesFaced with rising numbers of COVID-19 cases, one hospital struggled to find adequate medical/surgical beds due to the challenges it had with discharging COVID patients. With a strong desire to address the need for surge capacity and to meet patient needs for inpatient rehabilitation, the challenge was met by the team at Henry Ford Macomb Hospital in Michigan, as you’ll learn during this edition of Monitor Mondays.Longtime RACmonitor contributor Angela Phillips will report on how the hospital kept the Inpatient Rehabilitation Facility (IRF) open, providing much-needed rehabilitation services while assisting the organization in meeting th...2020-06-0832 minMonitor MondaysExclusive: COVID-19 and Contact TracingNew York City-based RACmonitor investigative reporter Ed Roche returned to Monitor Mondays to report on developments in contact tracing: one of the newest tools in the fight to contain the deadly novel coronavirus that causes COVID-19.A hefty amount of money is being invested in contact tracing, including the development of new automated tools. But Roche reports his concern that some of the models being proposed may complicate how we exercise our Constitutional right to privacy.Other segments to be featured during the live broadcast include the following:RAC Report: Healthcare attorney...2020-06-0129 minMonitor MondaysExclusive: Mitigating the Uncontrolled Spread of COVID-19: An Epicenter Case StudyLong-term care providers nationwide are seeking to identify ways to mitigate the uncontrolled spread of the COVID-19 virus amid vulnerable populations. Case in point: “drop teams” of physicians, infection preventionists, and nurses that could be deployed to any post-acute care space that was felt to be at risk.After seeing an outbreak at LifeCare Center in Kirkland, Wash., physician leadership and case management at MultiCare in Spokane, Wash. brainstormed ways to prevent a similar local occurrence.During this edition of Monitor Mondays MultiCare’s Ben Kartchner, MD, reports on how the drop teams are working in the...2020-05-1855 minMonitor 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 MondaysEXCLUSIVE: COVID-19 Town Hall – $50 Billion Aid Package: Pitfalls and RisksPursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the U.S. Department of Health and Human Services (HHS) has allocated $50 billion to providers and other healthcare facilities in the form of a one-time payment, which does not need to be paid back.The payment comes with terms and conditions that recipients must follow, however, including permissible uses for the payment – and failure to follow the terms and conditions, including documentation requirements, may result in an audit or other allegations of fraud and abuse.Other segments to be featured during the live broadcast in...2020-05-0455 minMonitor MondaysEXCLUSIVE: A UM Dispatch from the Front Lines of the COVID-19 PandemicThe global COVID-19 pandemic has presented a multitude of logistical challenges to healthcare providers across the country and beyond. But few are as daunting as the protocols utilization management (UM) directors are being asked to implement regarding patient status assignment.Delivering a riveting report from the front lines of the pandemic during this edition of Monitor Mondays, Stephanie Van Zandt, MD, Medical Director and Physician Advisor with BayCare Health System, a nonprofit healthcare organization that connects Florida residents with services at 15 hospitals across the state.Van Zandt describes the pitfalls and intricacies of the five-pronged...2020-04-2755 minMonitor MondaysEXCLUSIVE: The COVID-19 Impact on Medicare Appeals“Although Office of Medicare Hearings and Appeals (OMHA) office space is closed to the general public, OMHA remains open for business with employees working under maximum telework flexibilities, per U.S. Office of Personnel Management guidance.” -OMHA website.Indeed, “OMHA hearings and appeals processing measures are proceeding as scheduled,” the notice reads. “Unless an appellant is notified directly that a hearing has been postponed or canceled, appellants should continue to appear for hearings by telephone, as scheduled.”Through teleconferencing and phone calls, many administrative law judges (ALJs) are exercising flexibility in rescheduling such hearings or granting ext...2020-04-2055 minMonitor MondaysEXCLUSIVE: The COVID-19 Impact on Custodial AdmissionsCustodial admissions are problematic for hospitals under normal circumstances. But now, incredible demands placed upon facilities by COVID-19 create even more challenges, as you’ll learn during the next edition of Monitor Mondays – when Juliet Ugarte Hopkins, MD, will return to the broadcast as its special guest to report on the issues that are hampering efforts to keep hospital beds open for the patients who require care for their medical conditions.Other segments to be featured during the live broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law...2020-04-1353 min
The Hospital Finance PodcastSuspension of Audits During the Coronavirus?In this episode, we are joined by Knicole Emanuel, Partner at the Potomac Law Group, to discuss the suspension of audits during the coronavirus pandemic. Learn how to listen to The Hospital Finance Podcast® on your mobile device. Highlights of this episode include: Background on why CMS will forego all audits unrelated to...2020-04-0809 minMonitor MondaysEXCLUSIVE: Monitor Mondays COVID-19 Town Hall Q&AWaivers from regulations, dire shortages of ICU beds, and scarce personal protective equipment (PPE), including gloves, gowns, and masks, are all part of the new normal as the coronavirus (COVID-19) continues to generate global headlines, especially in the United States.Amid a cacophony of misinformation, providers and patients are searching for clarity in this fog of war. That time has come. Next Monday, the long-running and authoritive voice of healthcare regulation, Monitor Mondays, will broadcast a live, 60-minute town hall, during which its panelists will answer your questions and those of your colleagues.The broadcast rundown...2020-03-3055 minMonitor MondaysEXCLUSIVE: COVID-19 by the NumbersDuring this of Monitor Mondays, senior healthcare analyst Frank Cohen, a computational statistician, reports on how anecdotal thinking is not evidence-based thinking, and it is difficult to draw conclusions without having all of the information – noting that’s exactly what is happening right now, as America grapples with the coronavirus (COVID-19).Other segments to be featured during the live broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel files her Monitor Mondays RAC Report.Audit Report: Sean M. Weiss, reports on the next audits you can expect to encounter....2020-03-2338 minMonitor MondaysExclusive: Big Pharma, Big Money, Big TroublesSeldom does a week pass without news about a pharmaceutical giant engaged in corporate wrongdoing. This week, the feds announced that they had filed a complaint under the False Claims Act (FCA) against Mallinckrodt ARD LLC. The complaint alleges that the pharmaceutical company “avoided paying hundreds of millions of dollars in Medicaid rebates due to significant drug price increases” as a result of “large increases in the price” of its drug H.P. Acthar Gel.Recently, pharmaceutical company Sanofi-Aventis U.S., LLC, agreed to pay $11.85 million to resolve allegations that it violated the False Claims Act by paying k...2020-03-0931 minMonitor MondaysHospital Price Transparency: Clearing Up the Compliance ConfusionContentious and confusing, the Centers for Medicare & 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 Monit...2020-03-0231 minMonitor MondaysExclusive: The Plight of Rural Health, Part IWith a 30,000-foot view of rural healthcare policies and regulations emanating from Washington, D.C., Leslie Marsh still recognizes the importance of having boots on the ground, serving as the chief executive of Lexington Regional Health Center in Lincoln, Neb.Marsh, who also serves as vice president of board of directors for the ruralMED Health Network, addresses the ubiquitous Z codes and their impact on the rural population, among other serious issues facing rural healthcare providers, during this edition of Monitor Mondays.Other segments to be featured during the podcast includes:RAC Report: 2020-02-1730 minMonitor MondaysExclusive: The AI Arms Race in Medicare AuditsThe artificial intelligence (AI) arms race is heating up. The use of AI by healthcare providers responding to a wave of audits initiated by AI systems is an escalation. As the government continues to deploy AI systems in Medicare audits, providers will respond with their own counter-measures, also using AI. Reporting our lead story during the next edition of Monitor Mondays will be RACmonitor investigative reporter Edward Roche, who continues to monitor the intensifying showdown. Other segments to be featured on the podcast include:RAC Report: Healthcare attorney Knicole Emanuel reports on the latest a...2020-02-1030 minMonitor MondaysWar on Drugs: EHR Vendor Admits to Receiving Illegal Kickbacks from Opioid PharmasPractice Function, Inc., a unit of Allscripts Healthcare Solutions Inc., engaged in an "abhorrent" scheme to help a pharmaceutical company push its extended-release opioids, according to a news release posted on Monday by the U.S. Department of Justice.The company agreed to pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software. Practice Fusion admitted soliciting and receiving kickbacks from a major opioid company in exchange for utilizing its EHR software to influence physician prescribing of opioid pain medications. Famed whistleblower attorney Mary Inman reports our lead story this edition...2020-02-0332 minMonitor MondaysBalancing Billing: A Swirling ControversyWhat once appeared to be a legislative slam dunk is now mired in controversy, this time fueled by the recently formed coalition dead-set against the proposed use benchmark payments.The Coalition Against Rate-Setting considers the practice tantamount to price-fixing. What will happen next to the compromise legislation, which was hammered out with bipartisan congressional support? Matthew Albright, chief legislative affairs officer for Zelis, reports our lead story during this edition of Monitor Mondays.Other segments to be featured on the broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel reports on...2020-01-2731 minMonitor MondaysWar on Drugs: Court Orders AmerisourceBergen to Hand Over Opioid-Related Documents to Pension FundAmerisourceBergen, one of the nation’s largest pharmaceutical wholesalers, must turn over records to pension fund shareholders probing to determine wrongdoing by the drug distributor’s board for the company’s multi-billion-dollar legal exposure from the nationwide opioid crisis.AmerisourceBergen was already facing two congressional investigations, plus a Drug Enforcement Administration (DEA) probe. Reporting on this developing story is famed whistleblower attorney Mary Inman, a partner in the London law office of Constantine Cannon.Other segments to be featured on the broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel reports on the...2020-01-2030 minMonitor Mondays2020: Look Out, Look Ahead2020 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 Ch...2020-01-1358 minMonitor MondaysHome Health and Hospice: State of the UnionIt’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare & 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 th...2019-12-0931 minMonitor MondaysRural Health: State of the UnionRural hospitals are an endangered species in America, with extinction a real possibility. In fact, the North Carolina Rural Health Research and Policy Analysis Center report that more than 120 hospitals have closed nationwide since 2005, with nearly 70 percent (or 83) of those closures occurring since 2010. Adding insult to injury is the recent announcement from the Centers for Medicare & Medicaid Services (CMS) that Monday, Dec. 2 is the deadline for critical access hospitals (CAHs) to submit a hardship exception to avoid the “Medicare downward payments.” To qualify, those hospitals must illustrate the use of certified electronic health record technology (CEHRT) in order...2019-12-0231 minMonitor MondaysDischarge Planning Conditions of Participation: The IMPACT and ConsequencesMany hospitals are likely in the throes of preparing to implement the Centers for Medicare & 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 ref...2019-11-2630 minMonitor MondaysMonitoring Patient Mortality: Compliance and QualityPatient mortality is closely monitored. If a patient dies, the hospital wants to be sure the documentation accurately portrays the acuity of the patient, with all diagnoses, so that when the risk of mortality is calculated with the complex algorithm used by federal agencies, it demonstrates that the death was not unexpected, and is not indicative of poor-quality care. Reporting the lead story during this episode of Monitor Mondays is Melinda Battaile, MD, physician advisor and clinical documentation advisor for Vidant Health in Greenville, N.C.Other segments to be featured on the broadcast include t...2019-11-1830 minMonitor MondaysKnown by the Company You Keep: Disclosures of AffiliationsDirect or indirect past affiliation with an individual the Centers for Medicare & 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 even...2019-11-1130 minMonitor MondaysAnatomy of an Algorithm: Optum Algorithm Under Fire for Alleged Racial BiasGiant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable.The results of a study published last week by Science revealed what researchers identified as a "significant racial bias" in Optum’s algorithm, which reportedly undervalues the healthcare needs of black patients. Although Science didn’t mention Optum by name, other news organizations have confirmed that it was, indeed, Optum.Reporting on this developing story during this edition of Monitor Mondays is RACmonitor investigative reporter and New York attorney Edward Roche, director of business intelligence for Barraclough New Yo...2019-11-0432 minMonitor MondaysCMS Site-Neutral Payments: Hospitals Win, CMS Loses, but the War is Not OverA federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings. The Centers for Medicare & Medicaid Services (CMS) could appeal the court’s decision on its site-neutral payment rule for hospital outpatient services. Score one for hospitals, but the war is far from over.Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.Other se...2019-10-2831 minMonitor MondaysFeds Putting the Squeeze on Medicare and Medicaid Payments: $252.6 Billion in Cuts ReportedActs of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American Hospital Association (AHA) and the Federation of American Hospitals.Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.Other segments to be featured on the broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel reports on the latest...2019-10-2129 minMonitor MondaysPDPM: New Reimbursement Model is Driving DisruptionThere have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS): the Patient-Driven Payment Model.Reporting on these new changes during this edition of Monitor Mondays will be Toby S. Edelman, senior policy attorney for the Center for Medicare Advocacy. The new PDPM system reverses the financial incentives that existed for 20 years. Instead of paying more money for more minutes of therapy that a resident at a...2019-10-1431 minMonitor Mondays340B Drug Program in CMS CrosshairsThe Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program.How will the information gathered by CMS be used, moving forward? And why is this action being taken by CMS? The agency has a history of attempted cuts to 340B reimbursement; the most recent such action by CMS occurred last December, after which a federal judge ruled against the move.Reporting our lead story during this edition of Monitor Mondays is Maureen Testoni, president and CEO of 340B Health.2019-10-0730 minMonitor MondaysDeveloping Story: Virginia Governor and MCOs Sued by Behavioral Health ProvidersAs expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause.The suit was filed by the Potomac Law Group.During this edition of Monitor Mondays, healthcare attorney Knicole Emanuel, a partner in the aforementioned law firm and a member of the RACmonitor editorial board, provides an update on the lawsuit as it makes it...2019-09-3029 minMonitor MondaysDeveloping Story: Virginia’s Behavioral Health Providers Under SiegeOther segments to appear during the live broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel reports our lead story on the mass terminations of behavioral healthcare providers in Virginia. Emanuel has also been at ground zero in Richmond this past week, representing the aforementioned association there. 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...2019-09-2330 minMonitor MondaysNo Time for SNFs: PDPM Becomes Effective Oct. 1Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM). Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to avoid a Recovery Audit Contractor (RAC) audit. Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel. Other segments to appear during the live broadcast include th...2019-09-1629 minMonitor MondaysRACs and SNFs: Referrals in the CrosshairsDo you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)?You need to know because the Recovery Audit Contractors (RACs) and other contractors are reviewing SNF referrals. Reporting our lead story is physician and attorney John K. Hall, founder of the Aegis Firm. Hall reviews such statutory and regulatory requirements while also making recommendations for audit readiness.Other segments to appear during the broadcast:RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report the latest audits by RACs and...2019-09-0930 minMonitor MondaysUnderstanding the Rules of Engagement at the ALJ LevelDespite an order from the U.S. District Court for the District of Columbia for the federal government to reduce the backlog of Medicare appeals, the requirements for victory in front of an Administrative Law Judge (ALJ) remain the same.During this edition of Monitor Mondays, David Mullens, a California healthcare attorney, will address some of those fundamentals.Other segments to appear during the podcast 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...2019-08-2631 minMonitor MondaysTwo Suicides and a Bankruptcy: Have Some Auditors Gone Rogue?Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable tragedy. RACmonitor Editorial Board member, investigative reporter, and New York attorney Edward Roche returns Monitor Mondays with this exclusive story about a durable medical equipment (DME) provider facing auditors who, in his words, had gone rogue.Other segments to appear during the live broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel returns to the...2019-08-1931 minMonitor MondaysAn Unsolved Mystery: Lifting the Suspension of Medicare FundsObtaining an injunction in federal court to lift a suspension of access to Medicare or Medicaid funds is rare, according to healthcare attorney Knicole Emanuel. As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons that might explain such a mystery during this edition of Monitor Mondays.Other segments to appear includes:IRF Report: Angela Phillips, considered to be one of the nation’s f...2019-08-1230 minMonitor MondaysChanges in the Works for Home Care ProvidersThe 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 Medicar...2019-08-0530 minMonitor MondaysMedicare Advantage Plans: Making Up Their Own RulesReports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare.Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.”This is but one example of Medicare Advantage (MA) plans misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care they provide to their members. Reporting on this d...2019-07-2930 minMonitor MondaysAuditors Will Target SNF Patient Condition, Not Services and Time RenderedThere was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits. Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documentation can easily lead to higher reimbursement – and the likelihood of audits leading to claim denials. Reporting on this development during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.Othe...2019-07-2231 minMonitor MondaysWhat to Do When a Government Agent Knocks on Your DoorAn older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records.In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary fines and penalties. What could have possibly triggered this investigation?Reporting this developing story during this edition of Monitor Mondays is Shannon DeConda, founder and president of...2019-07-1529 minMonitor MondaysThe Seema Verma Blog Post That’s Making Providers AnxiousSeema Verma, the Centers for Medicare & 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 b...2019-07-0830 minMonitor Mondays340B Drug Survey Reveals Help to Rural HospitalsUnder siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey. Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey results and the import of its findings during this edition of Monitor Mondays Maureen Testoni, president and CEO for 340B Health. Other segments to appear during the live broadcast include:RAC Report: Healthcare at...2019-07-0131 minMonitor MondaysYea or Nay? Surprise Balance Billing Legislation Heads for a VoteU.S. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health Committee, appears to be ready to shepherd his 165-page draft legislation on surprise balance billing for a vote next week. In their push to get legislation prohibiting such billing through before the August recess, both the House and Senate have held hearings in the past two weeks on the various approaches to the problem. Those hearings have made the industry battle lines clearer, in terms of how the various industry sectors think that out-of-network providers should be compensated by payors. Although no single approach ap...2019-06-2432 minMonitor MondaysResponding to Emergency Department Claim DenialsMost likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years. But how can you and your team effectively deal with them? What tools and techniques are available? During this edition of Monitor Mondays, John K. Hall, MD, founder of The Aegis Firm and the newest member of the RACmonitor editorial board, will make his debut appearance on the broadcast to report on how payers are denying cl...2019-06-1729 minMonitor MondaysA Legend Returns to Monitor MondaysDaniel Levinson, former head of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), will make his first broadcast appearance on Monitor Mondays since his announced retirement earlier this year.During his 15-year stint as the nation’s top healthcare watchdog, Levinson oversaw investigations into controversial health issues, including what was described as the largest healthcare fraud takedown in history in July 2017, when more than 400 defendants in 41 judicial districts were charged with participating in schemes involving about $1.3 billion in false billings to Medicare and Medicaid. Other segments to appear on the...2019-06-1028 minMonitor MondaysNo Surprise: Stakeholders Fight to Solve Surprise BillingThe fight is on, and combatants are sparring over how to implement a legislative ban on surprise balance billing. In recent congressional testimony, providers, payers, and hospitals have clashed on how to keep patients from being stuck with huge expenses, with each side blaming the other for being intransigent. One of the major issues is how out-of-network doctors should be reimbursed, and at what rate. Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis and the former Director of the Administrative Simplification Group of th...2019-06-0329 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 MondaysIs Disallowing an Appeals Process for a Decrease in Medicare Payments Unconstitutional?The Centers for Medicare & Medicaid Services (CMS) recently announced that 800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row (the HAC Reduction Program has only been in existence for five years). The Code of Federal Regulations does not allow a hospital to appeal the determination of poor results in this program, whereas if you are penalized by a Recovery Audit Contractor (RAC) or a Zone Program Integrity Contractor (ZPIC), you do have the right to appeal. W...2019-04-1531 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 MondaysRemoving the Surprise from ED BillingPick 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 ye...2019-03-1130 minMonitor MondaysSepsis-3: Not in New YorkOn Tuesday, the Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2.Dennis Jones, the administrator of patient financial services for Montefiore Nyack hospital, was there Tuesday when HANY made the announcement during its regularly scheduled managed care advisory group meeting. Jones, who was among the earliest correspondents to join Monitor Mondays in 2010, will return to the broadcast...2019-01-2130 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 MondaysThe Dilemma of Sepsis ReportingControversy 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 & 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...2018-12-1031 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 Mondays2019 MPFS and OPPS Final Rules: Where Are We TodayLong awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to the regulations governing evaluation and management (E&M) services.For an in-depth analysis of both the MPFS and the OPPS newly released final rules, Monitor Monday has brought together a pair of industry experts for this edition of the broadcast: Duane Abbey, president of Abbey...2018-11-0530 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 MondaysUnitedHealthcare Puts Sepsis in the CrosshairsUnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present. If reviewers find no SOFA score in the medical record, that could spell trouble – audit trouble. Reporting on this topic during this edition of Monitor Mondays is Edward Hu, MD, executive director of Inpatient Physician Advisor Services for the University of North Carolina Health Care System and president of the Ame...2018-10-0831 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 min
Talk Ten Tuesdays2019 IPPS Updates: Reviewing Major Disease Category 18In this edition of Talk Ten Tuesdays Chuck Buck and Holly Louie, RN welcome special guest Dr. Emmel Golden, a physician associate and medicine lead for Enjoin. Dr. Golden, board-certified in internal medicine and pulmonary disease, will report on, among other topics, those associated with major disease category 18, including the confusing aspects of coding systemic inflammatory response syndrome, or SIRS.
Other segments to be featured on the broadcast include:
News Desk: Knicole Emanuel, Esq, anchors the Talk Ten Tuesdays News Desk and reports on Medicare waivers in times of natural disasters. Knicole is a partner at Potomac Law...2018-09-1829 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 MondaysCase Management in the ED: Getting Patient Status Right the First Time
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...2018-07-1631 minMonitor MondaysAlleged Bias Found in Extrapolation Audits “Literally billions of dollars a year are being extorted from healthcare providers due to a system of rules, regulations, and guidelines that are not outdated, but just plain wrong,” writes senior healthcare analyst Frank Cohen, director of analytics and business Intelligence for DoctorsManagement in the current edition of the RACmonitor e-News. Cohen joined the Monitor Mondays broadcast to make his case and suggest strategies for improving what he believes is a flawed system of medical record auditing.
Other segments to be featured on the broadcast include:
Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advi...2018-06-0430 minMonitor MondaysLevel of Care Versus Level of Care Billed: An Emerging Audit ProblemThe problem begins like a blip on the radar screen: a curious anomaly that gradually grows more menacing. That is what Andrew Hughes, MD, and Charles Locke, both at Johns Hopkins, are noticing: an uptick in denials related to level of care provided versus the level of care billed.
The majority of the denials arise when documentation indicates that a patient is "stable for downgrade" and a transfer has been initiated but not yet effectuated due to a lack of an available bed, reported Dr. Hughes, who was the special guest on this edition of Monitor Mondays.2018-04-3029 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 MondaysFacebook: Healthcare’s Social Media MenaceFacebook CEO Mark Zuckerberg faced two days of grilling by Congress last week to address data misuse in the wake of revelations that millions of Facebook users had their private information given away to political consulting firm Cambridge Analytica in the run-up to the 2016 Presidential election.
Zuckerberg testified before Congress that about 87 million users had their Facebook data taken without their permission. Of those users, many were healthcare professionals who inadvertently allowed hackers and criminals the information they need to break into healthcare systems.
Reporting this developing story will be RACmonitor national correspondent and healthcare c...2018-04-1630 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 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 Mondays2018: Look Out, Look AheadMonitor 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 2018 during this 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.
Ronald Hirsch, MD, FACP, CHCQM
Angela Phillips, PT
Timothy Powell, CPA
J. Paul Spencer, CPC, CPC-H
Andrew Wachler, Esq.
2018 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system...2018-01-1558 min