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. These are done on outlier claims, particularly for Medicaid HMO claims, as well as commercial and even Medicare Advantage claims.

The denials are for commonly billed services and items such as supplies, IV solutions, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc. The rationale given for the denials is that the charges are “unbundled” and should be included in a room rate or a procedure charge, or labeled “routine,” and thus not separately billable or payable.

Appeals are reported to be very time-consuming, with no guarantees of success. Reporting our lead story during this edition of Monitor Mondays will be Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc. Gilliland reports on her experience and efforts to appeal what she describes as “spurious” denials. 

The broadcast rundown also will include:

• Monday Focus: Readmissions: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for excessive readmissions that are often the result of a poor discharge process and medical decision-making. Reporting on readmissions will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital in New York.
  
  
• Providence Lawsuit: Nationally recognized whistleblower attorney Mary A. Inman, reports on 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.
  
  
• Monday Focus: TPE Audits. Two different Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs), two different audits, both for the same issue: knee orthotics. Reporting on this topic will be Leann Wilhelm, a compliance officer for Kinex, a multi-state DME company located in Milwaukee, Wisc.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.