Best RACmonitor Podcasts (2024)

1
Simplifying the Two-Midnight Rule: Simple as 1, 2, 3 30:19

2h ago30:19

30:19

Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements. For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials. During …

1
Denials Going from Bad to Worse 28:52

1h ago28:52

28:52

Denials in healthcare are a problem. Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA). Hut reports that MA plans are classifying hospital stays as outpatien…

1
Sex, Lies and Turmoil 27:30

1d ago27:30

27:30

A pediatrician under investigation related to accusations that she had engaged in sexual relations with a male patient, having lied about it when applying for another healthcare position, was recently sentenced for making false statements. In another case, a federal contractor agreed to resolve False Claims Act allegations in connection with a gove…

1
The Two-Midnight Rule: Presumption of Risk 26:48

9d ago26:48

26:48

Could you and your care team be at risk when you upgrade a patient from observation to inpatient simply because the patient passed a second midnight in the hospital, based on the Centers for Medicare & Medicaid Services (CMS) contentious Two-Midnight Rule? And what about the expectation? How does expectation enter this equation? And finally, what s…

1
False Claims Act Violation: Unnecessary Drug Testing Flags Feds 26:56

16d ago26:56

26:56

The U.S. Department of Justice (DOJ) has reported that one of America’s largest urine drug-testing companies has agreed to pay $27 million to resolve allegations of unnecessary drug testing and illegal remuneration to physicians. The False Claims Act allegations resolved by this settlement were originally brought in three lawsuits filed by whistleb…

1
340B Drug Rebates: Old Debate Revived, But Shot Down 27:58

23d ago27:58

27:58

A major drug company’s attempt to turn 340B drug pricing program discounts into rebates made big headlines in recent weeks. Maureen Testoni, president and CEO of 340B Health, will review how this potentially major upheaval came about, how 340B stakeholders responded, and how the drugmaker backed off after the federal government threatened it with m…

1
Violence in America’s Hospitals 28:04

30d ago28:04

28:04

As violent crime has trended slightly downward throughout the United States over the last year, a wound to this country’s collective psyche that appears reluctant to close is workplace violence in America’s hospitals. Reporting the lead story during the next live edition of Monitor Mondays will be special assignment contributor Dennis Jones, senior…

1
Whistleblower Report: Oak Street Health Agrees to Pay $60M to Resolve Alleged False Claims Act Liability in Medicare Advantage Patient Recruitment Scheme 28:41

1M ago28:41

28:41

Oak Street Health, headquartered in Chicago and a wholly-owned subsidiary of CVS Health since 2023, has agreed to pay $60 million to resolve allegations that it violated the False Claims Act by paying kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street Health’s primary care clinics, according to a news release…

1
Exposing Challenges to Getting Paid by Medicare Advantage 29:00

2M ago29:00

29:00

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays. Pace, in making the statement, was referring to rules and…

1
How to Ensure Correct Inpatient Status 30:12

2M ago30:12

30:12

What’s wrong with this picture? With more than 10 years of the Centers for Medicare & Medicaid Services (CMS) Two-midnight Rule now behind us, one would presume that most healthcare professionals should know what determines an inpatient status. But some don’t. That is why RACmonitor has invited renowned physician and attorney Dr. John K. Hall to re…

1
New Study Reveals America’s Big Hang-up with Healthcare 28:58

2M ago28:58

28:58

A comprehensive new survey featuring responses from more than 1,500 U.S. patients reveals that they are not only frustrated by poor provider support, but also are experiencing tangible health setbacks – especially when waiting to refill prescriptions and being placed on hold while waiting to speak to a caregiver. Israel Krush, CEO and Co-Founder of…

1
Federal Officials Announce Medical Relief in Wake of Hurricane 27:15

3M ago27:15

27:15

In response to the devastation caused by Hurricane Debby, now Tropical Storm Debby, the Centers for Medicare & Medicaid Services (CMS) has announced additional resources and flexibilities to support the affected states of Florida, Georgia, and South Carolina. Following President Biden’s emergency declarations and U.S. Department of Health and Human…

1
There’s a New Sheriff in Town: New DOJ Program Intends to Snare Even More FCA Fraudsters 28:37

3M ago28:37

28:37

The U.S. Department of Justice (DOJ) has a new whistleblower reward initiative called the DOJ Corporate Whistleblower Awards Pilot Program. The Program, which seeks to fill gaps left by existing whistleblower reward programs, incentivizes whistleblowers to bring tips to the DOJ about types of healthcare fraud not already covered by the False Claims…

1
FY 2025 IPPS: The Clinical Report 31:07

3M ago31:07

31:07

The Inpatient Prospective Payment System Final Rule for Acute Care and Long-Term Care hospitals in the 2025 fiscal year (FY) continues to generate interest from providers, payers, hospital administrators, vendors, and consultants. But what are the significant takeaways for stakeholders as they prepare for the government’s fiscal year, which begins …

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

4M 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

4M 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

4M 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

4M 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

4M 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

5M 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

5M 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

5M 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

5M 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

6M 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

6M 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

6M 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

7M 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

7M 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

7M 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

7M 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

8M 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

8M 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

8M 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

8M 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

8M 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

8M 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

9M 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

9M 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

9M 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

10M 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

10M 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

10M 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

11M 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

12M 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

12M 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

1y 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

1y 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

1y 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

1y 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

1y 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…

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