Monitor Mondays

Monitor Mondays
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 l?

Known by the Company You Keep: Disclosures of Affiliations
Nov 11 • 30 min
Direct or indirect past affiliation with an individual the Centers for Medicare & Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare.
Anatomy of an Algorithm: Optum Algorithm Under Fire for Alleged Racial Bias
Nov 4 • 32 min
Giant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable.
CMS Site-Neutral Payments: Hospitals Win, CMS Loses, but the War is Not Over
Oct 28 • 31 min
A federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings.
Feds Putting the Squeeze on Medicare and Medicaid Payments: $252.6 Billion in Cuts Reported
Oct 21 • 29 min
Acts of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American…
PDPM: New Reimbursement Model is Driving Disruption
Oct 14 • 31 min
There have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS):…
340B Drug Program in CMS Crosshairs
Oct 7 • 30 min
The Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program.
Developing Story: Virginia Governor and MCOs Sued by Behavioral Health Providers
Sep 30 • 29 min
As expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental…
Developing Story: Virginia’s Behavioral Health Providers Under Siege
Sep 23 • 30 min
Mass terminations of behavioral healthcare providers in Virginia.
No Time for SNFs: PDPM Becomes Effective Oct. 1
Sep 16 • 29 min
Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM).
RACs and SNFs: Referrals in the Crosshairs
Sep 9 • 30 min
Do you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)?
Understanding the Rules of Engagement at the ALJ Level
Aug 26 • 31 min
Despite an order from the U.S. District Court for the District of Columbia for the federal government to reduce the backlog of Medicare appeals, the requirements for victory in front of an Administrative Law Judge (ALJ) remain the same.
Two Suicides and a Bankruptcy: Have Some Auditors Gone Rogue?
Aug 19 • 31 min
Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable…
An Unsolved Mystery: Lifting the Suspension of Medicare Funds
Aug 12 • 30 min
As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons that might…
Changes in the Works for Home Care Providers
Aug 5 • 30 min
The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients.
Medicare Advantage Plans: Making Up Their Own Rules
Jul 29 • 30 min
Medicare Advantage (MA) plans misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care they provide to their members.
Auditors Will Target SNF Patient Condition, Not Services and Time Rendered
Jul 22 • 31 min
There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits.
What to Do When a Government Agent Knocks on Your Door
Jul 15 • 29 min
A rural West Virginia physician, plans to tell a jury of his peers that he didn’t swindle Medicare for money at their expense.
The Seema Verma Blog Post That’s Making Providers Anxious
Jul 8 • 30 min
Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of…
340B Drug Survey Reveals Help to Rural Hospitals
Jul 1 • 31 min
The controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey.
Yea or Nay? Surprise Balance Billing Legislation Heads for a Vote
Jun 24 • 32 min
Hearings have made the industry battle lines clearer, in terms of how the various industry sectors think that out-of-network providers should be compensated by payors.
Responding to Emergency Department Claim Denials
Jun 17 • 29 min
Most likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years.
A Legend Returns to Monitor Mondays
Jun 10 • 28 min
Daniel Levinson, former head of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), will make his first broadcast appearance on Monitor Mondays since his announced retirement earlier this year.
No Surprise: Stakeholders Fight to Solve Surprise Billing
Jun 3 • 29 min
The fight is on, and combatants are sparring over how to implement a legislative ban on surprise balance billing.
340B Dodges Another Bullet
May 20 • 29 min
A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program.
Inpatient versus Outpatient: Status of Psych Patients in the ED
May 13 • 29 min
Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient
New Proposal for Dual-Eligibility Beneficiaries: Good Intentions or Cost Cutting?
May 6 • 29 min
The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid.
Congressional Action on Surprise Balance Billing
Apr 29 • 30 min
News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing.
ECAPE: Revealing the New Backlog Buster at OMHA
Apr 22 • 30 min
New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals.
Is Disallowing an Appeals Process for a Decrease in Medicare Payments Unconstitutional?
Apr 15 • 31 min
800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row.
Observation and Outpatient Status: Heading for Another Court Fight
Apr 8 • 31 min
The use and apparent abuse of observation and outpatient status are expected to have its day in court – again.
CMS and Prescription Drug Prices, Part II: 340B State of the Union
Apr 1 • 30 min
the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered under the 340B federal drug program.
CMS and Prescription Drug Prices, Part I: 2019 Drug Spending Dashboards
Mar 25 • 28 min
First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousands of more drugs across Medicare Parts B and D and Medicaid.
Single-Payer Healthcare for New Yorkers: An Option on the Table
Mar 18 • 29 min
Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no access to healthcare.
Removing the Surprise from ED Billing
Mar 11 • 30 min
The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as “non-emergent.”
Challenging the Ambiguity of an Agency’s Regulations
Mar 4 • 30 min
Focusing on the U.S. Supreme Court (SCOTUS) taking up the case of Kisor vs. Wilkie (U.S. Marine James Kisor vs. the U.S. Department of Veterans Affairs).
Forensic Audits: Spurious or Genuine? Part II
Feb 25 • 29 min
Reaction to the reporting here on forensic audits continues to reverberate. Michael Lewis, president of Financial Review Services of Houston, Tex. continues our reporting on this topic during this episode.
Forensic Audits: Spurious or Genuine?
Feb 18 • 30 min
Many hospitals are seeing increasing numbers of significant payment reductions that are the result of so-called “forensic” or other reviews conducted by third-party auditors.
Is 340B at Risk?
Feb 11 • 31 min
It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place.
Out of Town by Sundown: “Must Be Done by End of Business Day.” Payer-Provider Pressure
Feb 4 • 29 min
Are you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied?
TKA 2.0: CMS Updates Total Knee Arthroplasty, Again
Jan 28 • 30 min
Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an updated memo.
Sepsis-3: Not in New York
Jan 21 • 30 min
Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment.
2019: Look Out, Look Ahead
Jan 14 • 58 min
Decisions being made in Washington will impact every practice, facility, and health system.
The Dilemma of Sepsis Reporting
Dec 10, 2018 • 31 min
Controversy swirls and denials of claims continue when it comes to reporting sepsis.
Dismissal Expected in Providence Health FCA Lawsuit
Dec 3, 2018 • 28 min
The expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States declined to…
Medicare Advantage Claim Denials: More Egregious, or More Awareness?
Nov 26, 2018 • 30 min
Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach?
Court Orders HHS to Clear Medicare Appeals Backlog
Nov 12, 2018 • 30 min
U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022.
2019 MPFS and OPPS Final Rules: Where Are We Today
Nov 5, 2018 • 30 min
2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for…
Provider-Based Clinics: Major Changes Coming Soon
Oct 29, 2018 • 30 min
The Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November
CMS Proposes Changes to Medicare Shared Savings Program: Probing the Impact on Providers
Oct 22, 2018 • 30 min
Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program.
Targeted Probe-and-Educate Audits: Three Strikes and You’re Out
Oct 15, 2018 • 30 min
Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out.
UnitedHealthcare Puts Sepsis in the Crosshairs
Oct 8, 2018 • 31 min
UnitedHealthcare is putting providers on notice.
CMS Proposes to Implement Home Health Pre-Claim Review Demonstration
Oct 1, 2018 • 32 min
Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas.
CMS Proposed Rule Intended to Alleviate Regulatory Burdens: Will it Work?
Sep 24, 2018 • 29 min
CMS released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494.
Compliance During Adversity: Hurricane Florence
Sep 17, 2018 • 30 min
U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that Medicaid and Medicare beneficiaries have access to medical care…
Last Chance to Take a Stand: Comment Period for Proposed E&M Changes Ends
Sep 10, 2018 • 30 min
Few proposals from the Centers for Medicare & Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E&M) reimbursement changes in the 2019 Medicare…
Anatomy of an Alleged False Claims Act Violation: The Providence Health & Services Lawsuit
Aug 27, 2018 • 30 min
A False Claims Act lawsuit has been filed by Integra Med Analytics against Providence St. Joseph Health, seeking $188.1 million related to alleged upcoding of Medicare claims.
CMS, Are You Listening? Podiatrists React Negatively to Proposed E&M Changes
Aug 20, 2018 • 30 min
“Podiatrists should not be discriminated against any further. E&M (evaluation and management) requirements are the same as (those for) other providers, and we should be reimbursed justly,”
Controversy Continues to Swirl Around Proposed E&M Changes
Aug 13, 2018 • 30 min
The Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes in the recently posted 2019 Medicare Physician Fee Schedule continue to generate controversy.
2019 Medicare Physician Fee Schedule and the Outpatient Prospective Payment System: Analyzing the Impacts on Providers
Aug 6, 2018 • 30 min
The Medicare Physician Fee Schedule/resource-based relative value scale (MPFS/RBRVS) regulations were formally published in the Federal Register on July 27, 2018. The Outpatient Prospective Payment System/Ambulatory Payment Classifications (OPPS/APCs) was…
Beware: Emerging New Payer Denial for COPD
Jul 30, 2018 • 29 min
An insurance company removed the diagnosis of COPD exacerbation because the treating physician chose not to treat using steroids. Could this denial be happening at your facility?
Court Ruling Creates Major Setback for 340B Drug Program
Jul 23, 2018 • 30 min
The 340B drug pricing program suffered a major setback Tuesday, when the U.S. Court of Appeals dismissed a key American Hospital Association (AHA) lawsuit to block $1.6 billion in cuts.
Case Management in the ED: Getting Patient Status Right the First Time
Jul 16, 2018 • 31 min
Case managers being situated in the emergency department (ED) appears to be a trend that is gaining traction nationwide, as results indicate that such a move helps determine appropriate status while also identifying patients who are appropriate for…
The Readmissions Quagmire: Medicaid Work Requirements Pose Audit Risks
Jul 9, 2018 • 30 min
Imagine the impact to the readmissions quagmire if benefits continue to be cut for the most vulnerable and disenfranchised members of society, or those most impacted by the social determinants of health (SdoH).
Appeal Relief Has Arrived: OMHA Implements Expansion to Settlement Conference Facilitation
Jun 25, 2018 • 30 min
The Office of Medicare Hearings and Appeals (OMHA) has implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process.
Pain Points of Pain Management Services
Jun 18, 2018 • 30 min
The Centers for Medicare & Medicaid Services (CMS) approved facet joint injections for auditing, warning that auditors will review medical documentation to determine that services were medically reasonable and necessary.
340B Drug Discount Program: What Happens Next?
Jun 11, 2018 • 30 min
Not unexpected but widely feared among healthcare providers, regulations setting 340B ceiling prices and establishing civil monetary penalties for drug manufacturers that knowingly and intentionally exceed those limits were delayed for the fifth time.
Alleged Bias Found in Extrapolation Audits
Jun 4, 2018 • 30 min
Guests suggest strategies for improving a flawed system of medical record auditing.
Total Knee Replacement: The Intersection of Functionality and Care Levels
May 21, 2018 • 30 min
Touching on the subjects of total knee replacement (TKR), E&M Services and Medicare advantage.
Latest News: Feds Delay 340B Enforcement Rules
May 14, 2018 • 29 min
The Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally…
IPPS Proposed Rule: Major Changes for IRF Providers
May 7, 2018 • 28 min
The dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear…
Level of Care Versus Level of Care Billed: An Emerging Audit Problem
Apr 30, 2018 • 29 min
We are noticing an uptick in denials related to level of care provided versus the level of care billed; a majority of the denials arise when documentation indicates that a patient is “stable for downgrade” and a transfer has been initiated but not yet…
Auditing Non-physician Practitioners
Apr 23, 2018 • 30 min
Could non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors?
Facebook: Healthcare’s Social Media Menace
Apr 16, 2018 • 30 min
Facebook CEO Mark Zuckerberg testified before Congress last week that about 87 million users had their Facebook data taken without their permission. Of those users, many were healthcare professionals who inadvertently allowed hackers and criminals the…
AHA Ordered to Fix the Medicare Appeal Backlog
Apr 9, 2018 • 30 min
Judge James E. Boasberg of the United States District Court for the District of Columbia has ordered the AHA to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the ALJ level.
Telemedicine: Significant Expansion, Followed by a Return to Normalcy
Apr 2, 2018 • 29 min
Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac’s report on Telemedicine, will be attorney Dale C. Van Demark, a partner at McDermott Will & Emery in Washington, D.C.
How to Predict the Likelihood of an Audit
Mar 26, 2018 • 30 min
During this episode Cohen, director of analytics and business intelligence for DoctorsManagement, reports on his latest findings, which could help you and your facility ward off an audit.
Anthem BlueCross BlueShield and UnitedHealthcare: New Worries for Patients and Providers
Mar 19, 2018 • 28 min
Patients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful…
Medicare and Medicaid RAC Audits: How Auditors Get It Wrong
Mar 12, 2018 • 30 min
Why, after nearly 10 years, do auditors still tend to get auditing wrong? Providing insight into this issue during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group.
Quelling the Confusion Over Modifier 25
Mar 5, 2018 • 30 min
“Anthem Blue Cross Blue Shield (BCBS) was set to implement a new processing edit with regard to the use of Modifier 25, effective March 1, 2018, but things didn’t go as planned,” reports Shannon DeConda, founder and president of the National Alliance of…
Time to Junk the Peer-to-Peer Process?
Feb 26, 2018 • 30 min
During this episode Juliet Ugarte Hopkins, MD, makes the case for abandoning your P2P process if the results are not satisfactory. Might the pressure of P2Ps even be contributing to some physicians considering opting out of Medicare?
Total Knee or Total Consternation?
Feb 19, 2018 • 30 min
Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your…
EMR and RAC Audits: Who Takes the Hit? Part II
Feb 12, 2018 • 30 min
Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor…
EMR and RAC Audits: Who Takes the Hit?
Feb 5, 2018 • 31 min
On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records?
HEDIS Reviews: How to Avoid Payer Abrasion
Jan 29, 2018 • 26 min
During this episode, special guest Greg Ford with MRO, explains the CMS’ Star rating systems as well as best practices to minimize payer abrasion.
Medicare Advantage: What’s the Advantage?
Jan 22, 2018 • 29 min
RACmonitor national correspondent J. Paul Spencer with DoctorsManagement investigates the issue of Medicare Advantage DRG audits.
2018: Look Out, Look Ahead
Jan 15, 2018 • 58 min
Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2018 during the next edition of the weekly Internet broadcast.