show episodes
 
Join Chuck Buck every Monday when he welcomes RACmonitor contributing editors and special guests for the latest regulatory audit news and information from CMS, OIG and OMHA. And gain valuable context and perspective that can only be found when you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: https://event.webcasts.com/starthere.jsp?ei=1235505&tp_key=eae2082467
 
Loading …
show series
 
President Joe Biden’s roughly $2 trillion infrastructure proposal, called the “American Job Plan,” includes approximately $400 billion to expand access to home care and community-based services, including access to long-term care provided under Medicaid. Reporting on the impact of this possible new fusion of funding during the next edition of Monit…
 
The initiative to vaccinate enough Americans to achieve herd immunity against the deadly coronavirus appears to be stalling – this in the face of increases in infection rates. According to data from the Centers for Disease Control and Prevention (CDC), the country has experienced an average of 65,000 new cases in the last seven days. Reporting our …
 
“Ridiculous denials are frustrating. Vent, and then respond,” Dr. Andrew Markiewitz advises. “But ask: are you arguing over the Titanic’s deck chairs?” “Insurers may correctly identify unsubstantiated diagnoses,” Markiewitz added – and, if their findings are legitimate, return the money. If the DRG or reimbursement doesn’t materially change, after …
 
Healthcare data breaches and the possibility of sanctions from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) are a rightfully terrifying possibility for healthcare administrators. But one hospital, MD Anderson Cancer Center, recently fought back and won. Reporting on the outcome of the decision handed down by …
 
Now that the auditing reset button has been pressed, you and other providers can expect a torrent of audits and recoupments. In this new aggressive auditing environment, propelled by commercial as well as governmental auditors, providers must continually update their approach in response. Against this chaotic background, there’s a new legal approac…
 
“Are your CFOs agitated by the increase of outpatients in inpatient beds because of the removal of total knee arthroplasty (TKA), total hip arthroplasty (THA), and hundreds of other procedures from Medicare’s Inpatient-Only List (IPO) list?” asked Julie Collins recently on the RAC Relief listserv. “If the surgeon’s office is securing the prior auth…
 
Changes 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 Eman…
 
After all this time, you could still be doing it wrong when it comes to Condition Code 44. If your hospital has been following the Medicare Condition Code 44 process associated with 42 CFR 482.30 because policy issued by the Medicare Advantage or commercial plans with which you’re contracted dictates its use, this may be the case, according to Dr. …
 
With the purchase by UnitedHealthcare (UNC) of Change Healthcare, providers are contemplating notable differences between two sets of quidelines. Change Healthcare owns InterQual criteria, while UHC has traditionally used MCG criteria. Becoming familiar with the variances in terms of observation timeframes, screening methodologies, severity of illn…
 
To ensure compliance in conveying device credits and to identify providers who do not, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has a specific Annual Work Plan item to address the matter. Either through targeted device credit audits or enveloped in broader general billing compliance regulations for ho…
 
Billions of dollars in overpayments are levied annually against healthcare providers by the Centers for Medicare & Medicaid Services (CMS), based on the use of extrapolation audits. And while thousands of extrapolation audits are completed each year, the targeted provider or organization most likely will appeal the use of extrapolation. In nearly a…
 
Even 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…
 
Most 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 possibl…
 
With 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 …
 
Amid 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 provide…
 
A 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 s…
 
The next upcoming Monitor Mondays broadcast will encompass a special live open-door forum, coming at the intersection of compliance and the coronavirus – a jarring combination, in light of the fact that the continuing viral pandemic has claimed the lives of more than 250,000 and infected more than 11 million in the U.S. It is here, at this critical…
 
There 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 …
 
The 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,…
 
The 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 Power…
 
Providers 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 & Associate…
 
More 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 dr…
 
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 …
 
The 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 bill…
 
The 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 ho…
 
The 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) auditor…
 
The 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 i…
 
Unlike 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 str…
 
In 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 b…
 
California 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…
 
The 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, a…
 
Center of Medicaid and Medicare Services (CMS) has been posting proposed rules for Medicare this past week. Already, CMS has issued the final rules for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, and Hospices; and we are still awaiting the final rule on the Inpatient Hospital payment rules. In light of these proposed rules we’ve a…
 
While the battle cry of “defund the police” has emerged from Black Lives Matter activists following the death of George Floyd at the hands of Minneapolis police, could there also be sufficient reason for providers to advocate to “defund the Unified Program Integrity Contractors (UPICs)?” According to RACmonitor investivative reporter Ed Roche, UPIC…
 
Two 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 c…
 
Could 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. T…
 
Last 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 …
 
The 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…
 
Don'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 Fi…
 
Welcome 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 …
 
Faced 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 i…
 
New 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. Bu…
 
Long-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 …
 
While 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 Medicar…
 
Pursuant 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, how…
 
The 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 duri…
 
“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 …
 
Custodial 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 ham…
 
The 1,000-bed USNS Comfort, a hospital ship that in the past has provided humanitarian relief around the world, is now anchored on Pier 90 in Manhattan to provide humanitarian relief as COVID-19, the illness caused by the novel coronarvirus, ravages New York City, now the epicenter of the pandemic. Also in New York City, the famed Jacob Javits Cent…
 
Waivers 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 c…
 
During 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).…
 
Loading …

Quick Reference Guide

Copyright 2021 | Sitemap | Privacy Policy | Terms of Service
Google login Twitter login Classic login