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 Integrity Manuel (MPIM) standards, plus how artificial intelligence (AI) is changing audit selection for 2025.

You and your team will receive expert analysis and practical guidance, as well as gain a better understanding of the true scope of improper payments.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 had remained unchanged despite evolving treatment modalities and technologies. 

During the next live edition of Monitor Mondays, Dr. James S. Kennedy will discuss this SOFA-2 revision and its expected impact on clinical validation for sepsis – defined by Sepsis-3 as a life-threatening organ dysfunction caused by a dysregulated host response to infection – and how facility clinical workflows can negotiate denial avoidance with payers with this challenging diagnosis.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Cate Brantley, senior healthcare legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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), according to a report from the U.S. Department of Justice (DOJ).

For analysis and context, Mary Inman, partner in the law firm of Whistleblower Partners, will be the special guest during the next live edition of Monitor Mondays.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 of Monitor Monday. She will also review a recent Congressional Budget Office (CBO) report, featured in a recent Senate committee hearing, that includes some misrepresentations about why the 340B program has grown in recent years.

As a special bonus, the longtime Internet broadcast produced by RACmonitor, will feature senior healthcare consultant Drew Updike, MD, who will recognize the tireless work being performed by the employees of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) who continue to work despite the federal shutdown, now in its fifth week.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 shutdown during the next edition of Monitor Mondays will be veteran ICD10monitor correspondent Timothy Powell. Powell is a regular panelist on the long-running Talk Ten Tuesdays Internet broadcast. In his day job, Powell, a certified public accountant (CPA), is a healthcare consultant.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 Velky, American Case Management Association’s Board President, will report on the sweeping changes in the newly signed One Big Beautiful Bill Act (OBBBA). The law includes nearly $1 trillion in Medicaid cuts, potentially affecting 12 million people. Changes to state-directed payments and provider taxes could slash hospital funding by $340 billion. With key programs like Disproportionate Share Hospitals (DSHs), telehealth, and Hospital at Home still in limbo, the impact on hospitals, especially in Medicaid expansion and non-expansion states, will be profound. Case management teams will face mounting challenges in discharge planning, amid shrinking resources.

Also during the second half of the 60-minute broadcast, Mary Beth Pace, American Case Management Association’s Board President-Elect, will report on the one of case management’s toughest challenges: difficult discharges. With shrinking resources and limited post-acute options, getting “ready-to-go” patients safely discharged is harder than ever. Mary Beth will share new tactics and practical strategies to help case managers navigate these complex situations.

Finally, Adriana Peters, Board President for the Association of Physician Leaders in Care Management (APLCM), will report on how hospitals can turn data into action through the smarter use of metrics, KPIs, and analytics-driven storytelling.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.
  
  
• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 will be senior healthcare analyst Frank Cohen,

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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 returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.
The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Three whistleblowers brought a durable medical equipment (DME) provider to its knees.

In two separate cases, the whistleblowers targeted Exactech, a manufacturer of total knee replacement (TKR) systems, resulting in a settlement of $8 million to resolve alleged violations of provisions of the False Claims Act (FCA).
Famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLP, will report the excoriating details of the settlement during the next live edition of Monitor Mondays.

The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley at Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Healthcare compliance just shifted fundamentally.
Traditional whistleblowers who needed inside access are being replaced by artificial intelligence (AI)-powered relators who mine public datasets and flag statistical anomalies that could signal fraud.
The U.S. Department of Justice (DOJ) logged 979 qui tam cases in 2024, many of which were reportedly triggered by mathematical outliers, rather than insider tips. Government agencies, such as the Centers for Medicare & Medicaid Services (CMS), have already recovered $820 million using algorithmic detection.
During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will reveal a possible solution for hospitals, health systems, and physician practices.
The weekly broadcast will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Adam Brenman, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.