Monitor Mondays
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© 2024 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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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.Providing analysis and context for the OIG report released June 3 during the next edition of Monitor Mondays will be James S. Kennedy, MD, a subject m...
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 possible prison time, if you lose the case.During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will review two re...
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 their impact on America’s delivery of healthcare services during the next live edition of Monitor Mondays will be RACmonitor investigative reporter Edwa...
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 another major case pending the unsealing of court documents expected this week.Among the two cases, one involves the U.S. and California versus ReNew H...
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 reporter Edward M. Roche will return to Monitor Mondays this coming Monday to report on the escalating AI arms race. Roche, who just completed an exclusive ...
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 will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds....
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 conference of the American College of Physician Advisors, Stephanie Van Zandt. In that role, Dr. Van Zandt had a front-row seat to the history-making...
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 doubled, tripled, quadrupled. Why take samples for review when AI can audit every single claim submitted? Providers can expect a deluge of demands for reco...
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. James Kennedy will unpack the challenges entities have with this hot billing compliance issue. Dr. Kennedy will also recommend an approach that attempt...
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 entitled from the government’s military health plan.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hir...
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 imagine provider executives simply giving up, rationalizing that non-compliance was the cost of doing business.But now there’s a chance for you...
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 providers fix this vexing problem, including addressing the onerous requirement for hospitals to produce their own machine-readable files (MRF...
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 landscape, unlocked by empowering the bedside physician to invoke the full potential of the Centers for Medicare & Medicaid Services (CMS) Two-Midnig...
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 took effect in January of 2021.The new mandate introduces a three-phase approach that began in January and will continue with new requirements e...
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 Hall will consider the ramifications of the demise of the so-called “Chevron Deference” currently enjoyed by federal agencies.Broadcast segments wil...
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 compliance, creating physician notes from doctor-patient conversations, and how AI could bridge knowledge gaps.Reporting on these latest developments i...
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 coding services for AGS Health, will report on why it’s essential for all eligible clinicians to report their score to prevent a 9-percent downward a...
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 and/or DRGs will be audited. Why? Because, statistically speaking, whatever the error rate reported by CERT is can help estimate the potential i...
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 both the general risk of an audit and the specific areas that might be at risk within your organization, according to senior healthcare analyst Fr...
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 action when faced with the next pandemic. Negotiations are underway now, and their outcome will be submitted to the 77th WHO Assembly in May.RACmon...
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