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 represented
Dr. James Taylor in his landmark False Claims Act (FCA) case against
Kaiser Permanente which resolved allegations of Medicare Advantage risk
adjustment fraud. Soltan also works on a major Medicare Advantage risk
adjustment fraud case against UnitedHealth Group on behalf of
whistleblower Benjamin Poehling.

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.

 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, legislative affairs liaison for
Zelis, will report on current healthcare legislation.

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 auditing. You’ll hear auditing news you won’t find anywhere else – except here the RACmonitor.

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.
  
  
• 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 liaison for Zelis, will report on current healthcare legislation.

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 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. 

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

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

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, documentation varies dramatically by provider, and even seasoned experts routinely disagree on the same chart. In this environment, extrapolation doesn't multiply truth—it amplifies uncertainty. Join us Monday during the long-running Monitor Monday when senior healthcare analyst Frank Cohen returns to the broadcast to debunk long-held beliefs regarding auditing, auditors and extrapolation. 

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. 

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

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

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

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 Monitor Monday Internet broadcast, famed whistleblower attorney Mary Inman will report the details of the amazing case, as a not-so-subtle reminder that crime doesn’t pay.

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. 

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

·      Legislative Update: Matthew Albright, chief government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

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

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 study performed by MDaudit and shared here on Monitor Monday, you will be able to judge for yourself.

During the next live edition of the long-running Internet broadcast, Ritesh Ramesh, CEO for MDaudit, will share the findings of his company’s annual 2025 Benchmark study.

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.
  
  
• 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.

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.