Monitor Mondays
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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://racmonitor.medlearn.com/racmonitor/podcasts/
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Healthcare documentation is no longer written for a single audience. Today, the medical record must simultaneously meet federal regulatory requirements and the coverage expectations of individual payers. While these systems often overlap, they originate from different authorities and serve different purposes. One governs compliance and program integrity; the other determines whether services are approved and reimbursed. As prior authorization expands and audit scrutiny intensifies, hospitals ...
The Centers for Medicare & Medicaid Services (CMS) has launched a new initiative titled Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH). CRUSH is a sweeping fraud prevention program. In an official news release posted Thursday, CMS reported suspending $5.7 billion in suspected fraudulent Medicare payments, preventing $1.5 billion in DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) billing, revoking more than 5,500 providers’ billing privileges, a...
Prior authorizations among Medicare Advantage plans have drawn criticism and concern from patients, providers, lawmakers, and regulators. But hospitals and doctors are uniquely positioned to advocate for their patients’ access to and coverage for care. What’s necessary is the need to understand the rules of the process. And Medicare Advantage plans have many of them. During the next live edition of the venerable Monitor Monday, the Internet broadcast, Richelle Marting, a healthcare attorney, ...
In a January 28 article, Dr. Ronald Hirsch verified that the Centers for Medicare and Medicaid Services (CMS) “has no problem” with the Aetna Severity Payment policy because it “meets the Two-Midnight Rule.” However, there is more to consider than compliance with 42 CFR 412.3. Federal regulations also state Medicare Advantage organizations must comply with Traditional Medicare laws including payment criteria for inpatient admissions at 42 CFR 422.101(b)(2). So the burning question...
It’s raining RACs. The Recovery Auditor Contractors (RACs), together with an alphabet soup of other private and public auditors, are coming down hard on hospitals and physician practices, looking for omissions and errors in submitted claims. Then there are seemingly contradictory rules from the Centers for Medicare & Medicaid Services (CMS). It’s little wonder that providers are treading cautiously as they look to thread the needle of compliance. This coming Monday, the venerable Monitor ...
There was a time when Relative Value Units (RVUs) felt like a stable currency – something you and others could take to the bank. That was then. This is now. Then, productivity could be measured, compensation plans could be managed, and economic models could assume relative stability in physician work measurement. Recently, actions by the Centers for Medicare & Medicaid Services (CMS) – culminating in the 2026 Physician Fee Schedule – signal a philosophical shift in how physician wor...
While many of you were enjoying the holidays, Kaiser Permanente was back in the news. This time, another whistleblower case which resulted in an amazing $556 million settlement to resolve allegations that the giant provider/payer fudged on its Medicare Advantage risk adjustment. Reporting the lead story during the next live edition of Monitor Mondays will be Liz Soltan, a New York-based senior associate at Whistleblower Partners. Soltan is a member of the firm's litigation team who ...
The Centers for Medicare & Medicaid Services (CMS) will block hospitals from performing certain interventions that are intended to change a child’s physical appearance to align an asserted sex identity. Reporting the lead story during the next live edition of Monitor Mondays will be independent physician consultant Dr. Drew Updike. More than four weeks since its last news broadcast, Monitor Mondays will return this coming Monday, Jan. 12, with a cadre of the smartest minds in healthcare a...
Whistleblower attorney Max Volman will return to the next Monitor Monday broadcast to report the latest news about whistleblowers. As we have learned, often “whistleblowers” are not insiders reporting wrongdoing; they tend to be outside the offending organization. Register now to listen to Max Voldman’s exclusive report. Broadcast segments will also include these instantly recognizable features: ● Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will...
For years, federal audit contractors have treated statistical extrapolation as the unassailable engine driving massive overpayment demands. The premise sounds reasonable enough: review a small sample of claims, calculate an error rate, and multiply across the entire population to produce a "statistically valid" overpayment figure. In a perfect world, this approach might hold up. But healthcare isn't a perfect world. It's a domain where coding is inherently subjective, docume...
The False Claims Act (FCA) suit was initiated by the U.S. government, not a traditional whistleblower. Nonetheless, the recent $45 million settlement with a Florida physician and his wound care group – Vohra Wound Physicians Management LLC – resolved allegations that group knowingly submitted claims to Medicare for medically unnecessary yet lucrative surgical procedures, when routine non-surgical wound management had actually been done. During the next live edition of the long-running ...
It’s raining RACs. And many other third party auditors. It seems like every submission of medical records is being scrutinized for omission and commission. Then enter artificial intelligence (AI). The use of AI in auditing, although relatively new, is here to stay. How is your facility faring compared to your peers? More audits? Less auditing? More denied claims? More money being recouped? Now you can see for yourself how you’re doing comparing to others. Thanks to the annual benchmark ...
The Centers for Medicare & Medicaid Services (CMS) recently released the 2026 Medicare Physician Fee Schedule. And while that’s not breaking news, the important news is that you and your team could benefit by understanding its hidden traps – so you can protect your revenue. During the next live edition of Monitor Monday, senior healthcare analyst Frank Cohen will reveal the latest developments in Medicare audit reforms and statistical extrapolation, including the Medicare Program In...
Recently, a new version of the Sequential Organ Failure Assessment (SOFA) score was introduced. Known as SOFA-2, this new definition aligns with organ dysfunction measurement in critically ill adults with current clinical practices, especially those diagnosed with sepsis. Published in the Journal of the American Medical Association (JAMA) on Oct. 29 and available at https://jamanetwork.com/journals/jama/fullarticle/2840822, this revised tool updates the original 1996 SOFA score, which h...
Durable medical equipment (DME) supplier Semler Scientific Inc., along with a former distributor, Bard Peripheral Vascular Inc. and its related companies, have agreed to pay $37 million to resolve allegations that they violated the False Claims Act (FCA) by knowingly causing and conspiring to cause the submission of false claims to Medicare for photoplethysmography tests performed using the FloChec and QuantaFlo devices, in connection with the diagnosis of peripheral arterial disease (PAD), a...
America’s hospitals will soon face an unprecedented rebate-based prescription drug model, come Jan. 1 – that’s when there will be as many as 10 major drugs subject to Medicare price caps. This development is expected to create administrative and financial challenges for hospitals, which will have to pay the commercial price for such drugs while waiting for the rebates. For analysis and context, Maureen Testoni, president and CEO for 340B, will be the special guest during the next live edition...
This marks the third week of the federal government shutdown: an epic failure of congressional leaders from both political parties who couldn’t agree on how fund the government for the fiscal year that began Oct. 1. And now many experts inside and outside of government believe this could be the longest shut down in history, surpassing the previous recordholder, which occurred, ironically, during the first term of President Donald Trump. Reporting on the nuances of the federal government shutd...
You’re invited to go behind the scenes and listen as case managers tell their stories – of long hours, little sleep, and always being ambushed by a bell ringing for help. These unsung heroes of healthcare are receiving their moment in the sun during the next live edition of Monitor Mondays, with a special 60-minute broadcast. The first half of the venerable weekly Internet broadcast will continue to bring you the news and information you’ve come to rely upon. During the second segment, Patti ...
Recently, a federal court vacated the Centers for Medicare & Medicaid Services 2023 Risk Adjustment Data Validation (RADV) Final Rule. This action is reshaping the landscape for Medicare Advantage compliance. The rule had authorized contract-level extrapolation and eliminated the longstanding fee-for-service (FFS) adjuster — two changes that dramatically increased the potential scale of overpayment recoveries. Reporting this developing story during the next live edition of Monitor Monday ...
A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO). Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government’s fraud detection radar. More on this topic will be reported during the next live edition of Monitor Mondays. That’s when whistleblower attorney Max Voldman ...
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