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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
 
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Johnson & Johnson, along with Gilead, are among the most recent pharmacy giants that have joined the list of others that are imposing restrictions on 340B drug price discounts to 340B hospitals. The latest information comes from a recent study conducted between December 2021 and March 2022 that reveals 16 other major pharmacies are flaunting the la…
 
2010 does not seem that long ago. It’s hard to believe we’re at Monitor Mondays broadcast No. 500 since then. But then again, let’s look at all we’ve seen change. Medicare started out with a one-midnight expectation for inpatient reimbursement. Then the Recovery Audit Contractors (RACs) moved in, showed us all the errors of our ways, and demonstrat…
 
With the growth of Medicare hospice services comes expanded oversight on claims and care quality. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has initiated a nationwide audit of hospice claims on the heels of multiple in-depth audits of such facilities. Unified Program Integrity Contractors (UPICs) and M…
 
How is one major hospital system reducing observation hours? Listen to the next live edition of Monitor Mondays to find out; that’s when Mary Beth Pace will return, by popular demand, to continue her compelling discussion on how she and her team at Trinity Health are taking steps to reduce the volume of observation hours. With her laser focus on pa…
 
What are your observation volumes doing to your bottom line? How much care do these patients get compared to your inpatients? If your facility is like most facilities, the billing status does not dictate the care provided; it just dictates the reimbursement you can expect to obtain. Worse yet, it does not leverage the patient’s insurance benefits c…
 
The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center…
 
Too many times, and in too many cases, providers are being subjected to flaws in methodologies and calculations used by auditors that lead to recoupment demands and other penalties. Aided by ambiguously written rules from the Centers for Medicare & Medicaid Services (CMS), unscrupulous auditors are often able to pounce on unsuspecting providers, wr…
 
The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned. However, there are also so-called “technical…
 
Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fr…
 
As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread, telehealth gained a foothold in America’s healthcare system, but that too is being subjected …
 
Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers. In the FAQ related to the prior authorization process released by the Cent…
 
It has been more than 10 years since Richard Bagnall filed suit against Kathleen Sebelius, in her role as Secretary of the U.S. Department of Health and Human Services (HHS). Since then, the case has been recaptioned several times, and bounced back and forth between the U.S. District Court for Connecticut and the U.S. Court of Appeals for the Secon…
 
In a terse, matter-of-fact announcement, the U.S. Department of Health and Human Services (HHS) is promising “significant enforcement” if providers have not complied with rules surrounding the Provider Relief Fund (PRF). This time, HHS is focusing on whether hospitals that received PRF payments complied with the surprise billing provisions of the P…
 
These complimentary special edition podcast from RACmonitor features Chuck Buck and John Zelem, MD as they review on-demand webcasts as well as preview upcoming webcasts. Dr. Zelem offers a unique physician perspective as he explains to listeners key learning objectives from these educational webcasts. Visit RACmonitor.com to view more informationa…
 
A growing number of drug manufacturers are imposing unlawful limits on 340B discounts, according to a newly released report by 340B Health. Currently, up to 13 such companies “just say no” to discounts for prescription drugs sold to safety-net hospitals and dispensed through community pharmacies. During the next live edition of Monitor Mondays, rep…
 
For many third-party Medicare auditors, the only rules they follow are their own, substituting personal preference for regulatory realities – and all in the name of claim denials. Every day in nearly every American hospital, health system, or physician practice, some dedicated healthcare professional asks, “how could they do this to us?” There is a…
 
The story first broke here on RACmonitor, when investigative reporter Edward M. Roche wrote about a case of double-dipping: the act of an auditor sampling and extrapolating against the same set of claims. As Roche explained in his exclusive RACmonitor article, the practice is like receiving two traffic tickets for a single instance of running a red…
 
It’s an amazing spectacle being played out on network television news, talk radio, and cable news outlets: the tug-of-war between the Biden Administration and the Supreme Court. So, the question remains: when is a mandate not a mandate? The back-and-forth over the Centers for Medicare & Medicaid Services (CMS) vaccine mandates for a wide range of h…
 
Public schools and facilities will be closed. Church bells will chime, while a number of flags will fly at half-mast. Because in 1983, former Republican President Ronald Reagan proclaimed that the third Monday of January would forever be observed as Martin Luther King Jr. Day. This coming Monday, Jan. 17, Monitor Mondays will honor the slain civil …
 
With the calamitous year of 2021 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future, on America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system for months or even years to come. With so many major …
 
The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe. The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its fe…
 
The auditing never stops, and the pace is quickening. New issues, new audits. But what are the costs for hospitals seeking to avoid audits? In one of the most comprehensive reports of its kind ever offered, RACmonitor and Monitor Mondays will bring on board prescient thought leaders to define the contours of this deepening healthcare regulatory cri…
 
"It’s time to stop getting stuck thinking we have a square-peg-and-a-round-hole problem, and focus on the fact that 42 CFR codifies and makes it law that a Medicare Advantage plan, even though it has autonomy in its contract, cannot offer less benefits than Medicare. Medicare Advantage plans cannot have more restrictive guidelines than Medicare; th…
 
The signs are ominous. New final rules have been published. All the auditors are there, ready to pounce. Warnings are being sounded. It’s a tsumani of audits. During the next live edition of Monitor Mondays, we’ll report on the latest news and most current updates, offering you our early warning alert system. You’ll receive the latest national audi…
 
Using artificial intelligence (AI), along with an uncanny ability to misinterpret rules, Medicare auditors – specifically, third-party auditors of Medicare Advantage (MA) plans – are ever-ready to pounce on healthcare providers. And too often, it’s like shooting fish in a barrel. The recent posting of three final rules will give auditors ample oppo…
 
The next three consecutive Monitor Mondays broadcasts will constitute an explosive series, exposing for the first time how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims. Learn about this outrageous behavior when RACmonitor investigative reporter Edward C. Roche presents the first edition of his…
 
Operating with virtual impunity, while relying on artificial intelligence, payor auditors have locked on to providers to deny claims that trigger audits. Acts of omission by providers are often deemed acts of commission in the eyes of auditors – and the audits often lead to recoupment. Even the slightest apparently innocuous action can trigger a ca…
 
Once suspended by COVID-19, claim audits are now back on the frontburner – Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Medicare Administrative Contractor (MAC) audits, plus Targeted Probe-and-Educate (TPE) audits are the new (or renewed) normal. It’s open season on providers, which is why, in large measure, the…
 
Big surprise. But not really. The Interim Final Rule (IFR) for the federal No Surprises Act, released last month, appears to offer bad news for out-of-network providers (OON), which does not come as a surprise to heathcare attorney Thomas Force, who will return to the Monitor Mondays broadcast. Force will explain, citing that the guidance is focuse…
 
The heat is on. As reported by RACmonitor, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) auditor, has started sending out documentation requests for short-stay inpatient audits. For targeted hospitals, Livanta will select 30 inpatient admissions of Medicare beneficiaries whose length of stay (LOS) was…
 
Rampant auditing by Medicare Advantage (MA) plans is a constant occurrence, with notable cases being reported weekly by RACmonitor. To wit: the recent U.S. Department of Justice (DOJ) filing of a complaint in intervention in a case against Independent Health of Buffalo, New York and its coding vendor, DxID. And there’s the recent case of Sutter Hea…
 
As 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 …
 
Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not pr…
 
They take no breaks. Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trust…
 
2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior. The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and do…
 
In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims. The decision is likely to have serious ramifications, to the tune …
 
The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits. Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the l…
 
Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries. Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn t…
 
Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight. Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation. Adding insult to injury is a ne…
 
The COVID-19 pandemic might have subsided somewhat, but in the eyes of the Centers for Medicare & Medicaid Services (CMS), it is anything but over, as the agency continues to treat providers as if it were still surging. In order of priorities, CMS is starting to push Targeted Probe-and-Educate (TPE) audits, according to healthcare attorney Andrew W…
 
SPECIAL GUEST Edward Roche, JD, PhD Director, Scientific Intelligence, Barraclough NY LLC ALSO FEATURING Matthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP; David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQ RACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant…
 
Six major U.S. drug manufacturers are refusing to provide 340B discount pricing for outpatient drugs sold to safety-net hospitals, community health centers, and public health clinics when those drugs are dispensed in community pharmacies. Will it take an act of Congress to intervene in this ongoing battle to restore 340B discounts and refund overch…
 
If your facility is considering submitting an amended claim request for a higher-weighted diagnosis-related group (HWDRG), be aware: the Centers for Medicare & Medicaid Services (CMS) has the authority to have your amended claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). And that alone could open…
 
There are lists upon lists of hospital rankings. But there’s one list you’ll certaintly want your hospital to avoid. A report from Johns Hopkins University has revealed that many of America’s top 100 hospitals are using predatory tactics to pursue lawsuits against patients. Highlighting this list are government hospitals as well as nonprofit health…
 
UnitedHealthcare is the latest insurer to join the growing lineup of payors that want to second-guess patients and deny payment for emergency department (ED) services after they’ve been rendered. As reported here on Monitor Mondays last week, UnitedHealthcare plans to extend no coverage or limited coverage to ED claims, retroactively – including an…
 
Are your physicians providing detailed documentation as they adhere the 2021 Evaluation and Management (E&M) Guidelines? Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement, is concerned that they might not be – which, he believes, squarely puts them in an uphill battle, defending themselves from quali…
 
There was a time when the word “logjam” seemed to be synonymous with the Administrative Law Judge (ALJ) hearings conducted under the purview of the Office of Medicare Hearings and Appeals (OMHA). Today, by all accounts, hearings are being scheduled almost back-to-back, and attorneys are scrambling to represent their clients during unprecendented ti…
 
“Incoming!” are the typical dreaded shouts heard from soliders hunkered down in bunkers when shelling begins. Today, across America, you can hear the same cries when it comes to claims auditing. Audits are incoming. Third-party auditors, governmental auditors, even auditors from the U.S. Department of Health and Human Services (HHS) Office of Inspe…
 
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