Best RACmonitor Podcasts (2024)

1
“Do the Crime, Pay the Fine:” DaVita to Pay$34 million to Resolve Allegations of Illegal Kickbacks 27:28

7h ago27:28

27:28

Denver-based DaVita Inc. has agreed to pay slightly more than $34 million to resolve allegations that it violated the False Claims Act (FCA). The U.S. Department of Justice (DOJ) reported in a news release that DaVita paid kickbacks to induce referrals to DaVita Rx, a former subsidiary that provided pharmacy services for dialysis patients, directin…

1
End of the Road for the ALJs? 30:07

4h ago30:07

30:07

Could the end be near for the administrative law judges of the Centers for Medicare & Medicaid Service (CMS). What about the Office of Medicare Hearings and Appeals (OMHA)? Could these entities be gone from the audit landscape? Case in point: the Supreme Court (SCOTUS) continues eviscerating executive powers. This time SCOTUS has limited the author…

1
Handle with Care: Taking Steps for Safe Transitions 29:12

9h ago29:12

29:12

Have you ever wondered how professional movers carefully pack everything? From expensive china to precious crystal stemware, they seem to have a knack and knowledge for how to prepare. When it comes to healthcare, how safe is the transition from hospital to home if a patient cannot get the services they need at home when they are ready to transitio…

1
No More Chevron? What Happens Next? 29:25

5d ago29:25

29:25

For nearly four decades, a judicial principle known as “Chevron deference” has guided the federal courts as they reviewed litigation associated with federal agencies. Chevron deference allowed legislators to leave statutes somewhat vague, assuming that an agency full of government experts would sort out the details and promulgate effective regulati…

1
Special Alert: DOJ Cracks Down on Nearly 200 Involved in Major Healthcare Fraud Schemes 28:55

29d ago28:55

28:55

In a late-breaking press release, the U.S. Department of Justice (DOJ) announced late Thursday that the agency had charged nearly 200 individuals accused with involvement in various healthcare fraud schemes estimated at $2.7 billion. Charges were brought against nurses, physicians, and others in a national sweep, and it was estimated that more than…

1
How a Different Type of Whistleblower Created a Lesson Worth Learning 28:57

21d ago28:57

28:57

A recent federal court decision in New Jersey demonstrates the viability of a different kind of whistleblower – in this case, a privately defrauded party. The most common type of a whistleblower under the False Claims Act (FCA) tends to be a corporate insider who sees fraud committed against the government by their employer or a company they work w…

1
The Human Touch at the Intersection of Artificial Intelligence and Denied Claims 28:50

1M ago28:50

28:50

Artificial intelligence (AI) is fast becoming a fixture in healthcare revenue cycle management (RCM), where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision. During the next live edition of …

1
OIG On the Prowl: Semi-Annual Report to Congress 31:15

2M ago31:15

31:15

They’re looking for fraudsters, going on the prowl for bad actors, as revealed in the latest semi-annual report to Congress compiled by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In this latest report, the government watchdog identified more than $2.76 billion in expected recoveries and receivables. Pr…

1
Jail Time, or Hefty Fine? 28:40

2M ago28:40

28:40

Most healthcare investigations by the U.S. Department of Justice (DOJ) result in settlements. Many times, the complete details of the settlements in underlying government cases are not fully disclosed. But sometimes, a provider ends up at trial. And when that happens, it often offers insights into what it takes to get hit with hefty fines – and pos…

1
New Medical Technologies: Are They Audit-Proof? 27:01

2M ago27:01

27:01

A deep dive into microbiology can reveal an up-close look at the cells that make up organs of the human body – and corresponding cancer treatments that leave no trace of damage. The science of medicine appears to be moving at the speed of light lately. But will new healthcare technologies be audit-proof? Monitoring these escalating changes and thei…

1
Healthcare Whistleblower Roundup: Recent Settlements Reach Nearly $10 Million 28:21

3M ago28:21

28:21

Two recent settlements to resolve allegations of violating the False Claims Act – both involving the virulent COVID-19 – are the latest in a series of actions that will be reported on during the next edition of Monitor Mondays by famed whistleblower Mary Inman, who also notes that her company, Whistleblower Partners, LLP, is poised to announce anot…

1
The AI Arms Race in Healthcare Auditing: Handicapping Winners and Losers 29:07

3M ago29:07

29:07

The arms race is heating up. On one side there are healthcare providers, and on the opposing side, an army operated by the auditors. Who will be the winners and losers? Are you safe? And how do you protect your facility from claim denials and takebacks, especially when auditors are using artificial intelligence (AI)? RACmonitor investigative report…

1
The Value of Peer-to-Peer Discussion 28:09

3M ago28:09

28:09

Do you have peer-to-peer (P2P) discussions? Are they useful? Are they valuable? And how do you know? Our own physician and attorney, Dr. John K. Hall, will offer his unique take on the value of P2P interactions and how you should measure it during his appearance as Guest Panelist on the next upcoming edition of Monitor Mondays. Broadcast segments w…

1
The Two-Midnight Rule: Navigating Treacherous Medicare Currents 27:49

3M ago27:49

27:49

Like seasoned harbor pilots navigating tugboats through natural and manmade hazards, physician advisors each day face the daunting task of guiding their hospitals through a labyrinth of Medicare rules and regulations. Reporting on those conditions during the next edition of Monitor Mondays will be the vice chair of the recently concluded national c…

1
Defense Strategies Against AI Audits 40:16

4M ago40:16

40:16

Artificial Intelligence (AI) software is now in the “hype phase” of adoption. It promises to increase the efficiency of medical audits. But also, AI is being touted as being able to handle much more data, examine many more cases, and instantly make decisions regarding medical necessity or inadequate documentation. The number of audits can be double…

1
Medicare Advantage “Schemes” in the DOJ Crosshairs 31:06

4M ago31:06

31:06

The recent $37 million settlement against Cigna regarding enhancing risk adjustment factor (RAF) scores —along with related litigation by the U.S. Department of Justice (DOJ)— highlight the aggressiveness of the federal government to crack down on entities for non-compliant billing practices. During the next live edition of Monitor Mondays, Dr. Jam…

1
Whistleblower Update: $300 Million in Alleged Fraud 31:19

4M ago31:19

31:19

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit that accuses Martin’s Point Health Care, along with five other providers in other states, of defrauding the government of more than $300 million, pertaining to allegations that the providers inflated patients’ risk scores to obtain higher payments to which they were not entitle…

1
How to Achieve a Clear Vision for Hospital Price Transparency 29:21

4M ago29:21

29:21

Since its launch in January 2021, the Hospital Price Transparency Rule from the Centers for Medicare & Medicaid Services (CMS) has been a vexing issue for many of America’s hospitals. Despite enforcement efforts from CMS, implementation for many providers has been onerous – so much so that when the latest requirements were issued by CMS, one could …

1
The Fix is in: Hospital Price Transparency Rule 28:32

4M ago28:32

28:32

Many of America’s hospitals continue to be challenged as it pertains to complying with the requirements from the Centers for Medicare & Medicaid Services (CMS) for implementing the agency’s rule on hospital price transparency. And that is why RACmonitor and Monitor Mondays are producing a three-part series, in collaboration with ClaraPrice, to help…

1
Empowering the Bedside Physician to Lower Observation Rates 30:32

5M ago30:32

30:32

America’s hospitals are currently facing a critical challenge: a flood of patients placed under observation, leading to lost revenue and operational disarray. Amid the confusion, questions arise. Even seasoned bedside physicians struggle with uncertainty in determining patient status upon admission. But fear not! There is hope in this chaotic lands…

1
Hospital Price Transparency Rule: An Important Update 28:53

5M ago28:53

28:53

There was a time when everyone in healthcare compliance and revenue cycle management was scrambling to implement the Hospital Price Transparency Rule. Now, nearly four years later, it’s back. The Centers for Medicare & Medicaid Services (CMS) 2024 Final Rule for Price Transparency marks the biggest change to the rule requirements since it initially…

1
Updated Episode | Chevron Deference: What Happens if There’s No Deference? 28:36

5M ago28:36

28:36

What happens if the Supreme Court of the United States (SCOTUS) dismantles decades of government agency discretion? Recent cases at SCOTUS indicate that this could happen. But what would be the consequences? During the next live edition of the long-running Internet radio broadcast Monitor Mondays, RACmonitor’s own physician and attorney Dr. John K …

1
Artificial Intelligence: Examining Promises, Skepticism, and Ethical Implications 30:48

5M ago30:48

30:48

The implementation of generative artificial intelligence (AI) in the Electronic Health Record (EHR) is one of several hot-button issues to be explored during the next live edition of the Monitor Mondays, the long-running Internet broadcast produced by RACmonitor. Other high-level considerations to be reported include leveraging AI in regulatory com…

1
What’s the Score with Your Physicians? Don’t Miss MIPS 30:00

6M ago30:00

30:00

The Merit-based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments. So, what’s the score for your physicians? Do they know? During the next live edition of the long-running Monitor Mondays, Leigh Poland, vice president of c…

1
How CERT Data Is Used to Target Providers 30:55

6M ago30:55

30:55

Auditors use the Comprehensive Error Rate Testing (CERT) study from the Centers for Medicare & Medicaid Services (CMS) as a way to target individual providers for potential recoupment. For example, if you get paid millions of dollars for some procedure codes or DRGs that have high error rates, it increases the likelihood that those specific codes a…

1
How to Protect Your Facility from CERT Audits 32:46

6M ago32:46

32:46

What’s important to know about the Comprehensive Error Rate Testing (CERT) program from the Centers for Medicare & Medicaid Services (CMS) is that auditors rely upon the results to target specific providers for recoupment audits. The more you know about CERT and the study results, the better position you will be in when it comes to understanding bo…

1
U.S. Forced to Comply with International Healthcare Law: Fact or Fiction? 30:32

6M ago30:32

30:32

Will the World Health Organization (WHO) be given the power to impose restrictive pandemic measures on countries, including the United States? Will it be legally binding? What are the challenges and opportunities for healthcare providers in the United States, and how will this be enforced? The member states of the WHO have been working on a plan of…

1
Look Out, Look Ahead 55:46

7M ago55:46

55:46

No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual. As the rest of the nation’s healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its…

1
2023 Healthcare Heroes to be Revealed 29:56

8M ago29:56

29:56

“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling the…

1
America’s Healthcare System: A Gordian Knot 28:01

8M ago28:01

28:01

RACmonitor investigative reporter Edward M. Roche, an intrepid regular monitor of America’s healthcare system, will return to Monitor Mondays for its next upcoming edition to report on how and why America’s healthcare system has tied itself into a Gordian Knot of complexity: interwoven strands of conflicting rules and regulations, different payment…

1
At the Intersection of AI and Medical Record Audits 30:14

8M ago30:14

30:14

The annual 2023 MDaudit Benchmark Report has been published, and it is relevatory in its analysis of articial intelligence (AI) and its impact on payment and revenue integrity. According to the report, the primary topic of discussion for the next live edition of the long-running Monitor Mondays Internet broadcast, the implications of AI are immense…

1
False Claims Act Roundup: 2023 Was a Very Good Year for the Feds 28:22

9M ago28:22

28:22

To quote the titular lyrics of the song popularized by Frank Sinatra for his very first No. 1 hit, “it was a very good year.” The U.S. Department of Justice (DOJ) announced that more than $2 billion in False Claims Act settlements and judgments were reported in the 2023 fiscal year. According to the DOJ, government and whistleblowers were “party to…

1
The Two-Midnight Rule Remains Too Confounding 31:17

9M ago31:17

31:17

The Two-Midnight Rule was first announced 10 years ago, October 2013, by the Centers for Medicare & Medicaid Services (CMS). Even today, though, the Rule remains an ongoing source of confusion for physicians as well as revenue cycle and finance experts. However, it also will take on new importance, as CMS promises that Medicare Advantage (MA) plans…

1
Violence in America’s Hospitals 26:21

9M ago26:21

26:21

Violence in America’s hospitals is an issue that is squarely on the minds of hospital administrators and staff. And the violence seen in our society has increasingly encroached into the medical workplace. This violence can be verbal, it can be physical, it can be disturbing, and it can be deadly. The escalation and prevalence of violence in hospita…

1
Lowering Prices, Increasing Supplies of Prescription Drugs 28:36

9M ago28:36

28:36

Congress and the Biden Administration continue to take a keen interest in issues related to prescription drug access and pricing. There is evidence of recent movement on Capitol Hill toward legislation aimed at addressing drug shortages affecting the healthcare system. The government also is implementing a plan Congress approved last year to lower …

1
When it Rains, it Pours: Understanding New Compliance Risks 28:50

10M ago28:50

28:50

So far in October, the U.S. Department of Justice (DOJ) has been very busy, securing settlements, pleas, and convictions ranging in value from $25 to $350 million. And just this month, DOJ announcements have featured settlements related to Anti-Kickback and Stark violations, as well as convictions in genetic testing schemes and guilty pleas for fra…

1
The Future of Cancer Treatment is Now: But Will Payers Pay? 27:26

10M ago27:26

27:26

Coinciding with National Breast Cancer Awareness Month (October), RACmonitor investigative reporter Edward M. Roche recently went to the laboratories of Memorial Sloan Kettering to investigate one of the most exciting scientific developments of the decade. Roche, who was among the first to introduce the healthcare compliance world to algorithms, ar…

1
Does the Two-Midnight Rule Apply to MA Plans? 29:14

10M ago29:14

29:14

The Centers for Medicare & Medicaid Services (CMS) is on record saying that Medicare Advantage (MA) payers must follow the Two-Midnight Rule as of Jan. 1, 2024. Yet, it has been reported by multiple hospitals that their MA plans have said their lawyers tell them that they do not have to follow the CMS directions on the Rule relative to inpatient st…

1
Peeking Behind the Curtain: AI and Claims Auditing 30:12

10M ago30:12

30:12

It’s little wonder that we will be reporting on artificial intelligence (AI)during the next live edition of Monitor Mondays. We were among the first to report on algorithms in claims auditing. But now, with so much attention being paid by the general news media to AI, its role in healthcare is gaining even greater attention and traction. So, during…

1
The Medicare Report Card: Assessing Areas for Major Reform 30:49

11M ago30:49

30:49

The United States spends more money on healthcare than any other country in the world. In 2021, U.S. healthcare spending reached $4.3 trillion. Medicare, which insures seniors, is America’s largest national health program, and therefore, it can and should be compared to its counterpart in other countries. So, how does the United States stack up? Ho…

1
Like Autumn Leaves, RAC Audits Keep Falling 29:44

11M ago29:44

29:44

The fall season is just about here. Colorful autumn leaves will be becoming ubiquitous, like claims denials and audits. And in this season, now is the time to “git ‘er done.” And Monitor Mondays is the place to do it. In preparation, following the long Labor Day weekend, RACmonitor producers of Monitor Mondays have enlisted the services of some of …

1
Assessing the Impact of Financial Woes Facing America’s Healthcare Providers 31:04

11M ago31:04

31:04

First there was COVID-19, which seemed to have torn a gaping hole in our nation’s patchwork quilt of care facilities. Add to this the rising costs of everything that touches healthcare, and now the growing list of Chapter 11 bankruptcies rippling through nursing homes and other facilities that provide care for America’s seniors. But will the tentac…

1
Physician Advisors: Revenue Drag or Stimulant? 28:09

11M ago28:09

28:09

Broadcast segments will also include these instantly recognizable features: Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds. The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors. Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikso…

1
What’s So Smart About Smart Hospitals? 31:04

12M ago31:04

31:04

Information technology has revolutionized many industries, including healthcare. “Smart” hospitals promise vast increases in productivity, and are being designed as integrated IT platforms linking together technology, patients, and providers in a complex web of interaction. But are the promised advantages of smart hospitals tangible, or are there a…

1
FY 2024 IPPS Final Rule: Looking Under the Hood for Hazards 29:36

12M ago29:36

29:36

The Centers for Medicare & Medicaid Services (CMS) FY2024 Inpatient Prospective Payment System (IPPS) Final Rule, posted on Aug. 1, reveals changes to the MS-DRG, CMS Hospital Acquired Conditions, and CMS Inpatient Quality Reporting Program affecting inpatient revenue cycles, quality reporting, and reputations essential to hospital operations. Ther…

1
Proposed Expansion of Medicaid RACs Includes Focus on Managed Care Payments 31:07

1y ago31:07

31:07

The Government Accountability Office (GAO) is recommending expansion of the Medicaid Recovery Audit Contractors (RACs) program, to include auditing of payments made to managed care organizations (MCOs), according to a GAO report released in June. Launched in 2011 as a consequence of the Patient Protection and Affordable Care Act (PPACA) by the Cent…

1
New Developments for Defeating Statistical Extrapolations Revealed 29:09

1y ago29:09

29:09

There is a buzz swirling within the healthcare auditing community. And thanks to RACmonitor investigative reporter Edward M. Roche, the news is buzzworthy. According to Roche, a legal team has developed two arguments that can be used by healthcare providers in federal court after the Administrative Law Judge (ALJ) process is completed. One argument…

1
$9 Billion Refund to 340B Hospitals at Risk 31:01

1y ago31:01

31:01

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to remedy Medicare Part B pay cuts made to 340B hospitals by issuing a lump-sum repayment to affected facilities. Last year, the U.S. Supreme Court ruled that those cuts, implemented by CMS from 2018 through most of 2022, were unlawful. Consequently, CMS proposed to offse…

1
Enforcement and Penalties, Guardrails and Risks: Understanding the 21st Century Cures Act 30:29

1y ago30:29

30:29

Although the 21st Century Cures Act was enacted in 2016, many hospitals today continue to struggle with effective implementation of its provisions and the goal of preserving patient access to medical records. Seven years later, however, meaningful guidance regarding its enforcement is here. One of the provisions requires developers not to engage in…

1
The Big Worry. The Big Unwind: Medicaid Disenrollment Keeps Rolling Along 29:44

1y ago29:44

29:44

At least 1.3 million Medicaid enrollees have been disenrolled as of June 20, according to the Kaiser Family Foudation (KFF) “Unwinding Tracker.” This estimate could be an under-count, KFF admits, due to state recordkeeping details. Yet the major issue looms on the horizon: what will happen to those who have lost their Medicaid benefits? Could a tsu…

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