We’ve all watched in awe as the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) began investigating the Medicare Advantage plans. Many were thinking, “it’s about time the payers get some of the heat providers feel.” But there’s something even better, according to most. That’s when the OIG investigates the government.

During the next live edition of Monitor Mondays, physician-attorney Dr. John K. Hall reviews an OIG audit of Medicare contractors and the Centers for Medicare & Medicaid Services (CMS). He’ll also explain what this means for providers.

Other segments will include these instantly recognizable broadcast features:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Most healthcare providers are swimming in shark-infested waters these days, ever-watchful for dorsal fins that signal imminent danger.  

At first there were the Recovery Auditors (RAs), created by the Centers for Medicare & Medicaid Services (CMS), to correct Medicare billing submitted by providers for services rendered to Medicare beneficiaries. And now, nearly two decades later, the RAs have been joined by several other auditors, and healthcare has quickly become a dangerous and expensive environment, especially given a new breed of sharks: the Medicare Advantage Organizations (MAOs), whose primary mission is to save money by denying claims in the name of compliance.

Join us next Monday for another live edition of the long-running Monitor Mondays Internet broadcast for a news round-up, and to learn of more lurking dangers and how to protect your facility’s revenue while remaining compliant, even amid all the turmoil.

Other segments will include these instantly recognizable broadcast features:

• OIG Report: Monitor Monday’s own physician and attorney, Dr. John K. Hall, will report on the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit of critical care billing at Leahy Clinic in Boston. If you have an ICU, you will need to hear his report.
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• SDoH Report: Marie Stinebuck, COO of Phoenix Medical Management, Inc, will report on the news that’s happening at the intersection of healthcare regulations and the SDoH. 
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
• Legislative Update: Adam Brenman, Federal Legislative Analyst for Zelis, will report on current healthcare legislation.

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Along the gulf shores of Mobile Bay in Alabama, at the crack of dawn you might hear shouts of jubilation from early risers there to witness flounder, soft-shell blue crabs, and gulf shrimp beach themselves due to the upward movement of oxygen-deprived bottom waters. The aftermath is a bounty of seafood on the sandy beaches, and hence the local dish known as “jubilee.”

Yet when it comes to local healthcare providers dealing with the Recovery Auditor (RA) Cotiviti, there is no jubilance – as you will hear Jennifer Bartlett explain during the next live edition of Monitor Mondays. Bartlett will report on the difficulty she and her team, along with other providers, face as they cope with the vagaries of one of the largest of the RAs in the U.S. 

Other segments will include these instantly recognizable broadcast features:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
• Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

The Medicare Physician Fee Schedule Final Rule for 2023 includes a provision for telehealth services – this following the temporary expansion of telehealth to beneficiaries during the COVID -19 public health emergency (PHE) that began March 1, 2020. Once the temporary PHE waivers terminate, what are the plans the Centers for Medicare & Medicaid Services (CMS) has for covering telehealth services for Medicare beneficiaries?

Join 3M consultant Colleen Deighan-Ejak during the next live edition of Monitor Mondays, when she will outline what is included in the Final Rule for Medicare telehealth services.  

Other segments will include these instantly recognizable broadcast features:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
• Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Healthcare attorney Andrew Wachler is an audit warrior, with war stories that will make you cringe in absolute disbelief.

And during the next live edition of Monitor Mondays, Wachler will tell some of these stories, sharing lessons to learn from his experience defending provider clients. He’ll report how failure to appeal a target, probe and educate (TPE) audit could establish a “pattern or practice of submitting claims fail to meet Medicare requirements” for the purpose of revocation of Medicare billing privileges.

Wachler will also share challenges related to lifting a Medicare payment suspension implemented across multiple Medicare Administrative Contractor (MAC) jurisdictions.

Other segments will include these instantly recognizable broadcast features:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
• Legislative Update: Adam Brenman, a federal legislative analyst, will substitute for Matthew Albright to report on current healthcare legislation.

Rumors, as they tend to sometimes, are spreading fast. Are there significant leadership changes coming within the largest Medicare Advantage (MA) plans for many beneficiaries in the mid-South region of the country?

Spend time with Jennifer Bartlett, longtime systems coordinator at Infirmary Health System in Mobile, Alabama, and it becomes clear that there could be a whole new ballgame, with new players. Are MA plans recalibrating their auditing approaches to providers? Could the payers be reacting to accountability tools?

Join us during the next live edition of Monitor Mondays, when Bartlett will report on her experience with Humana and UnitedHealthcare – and how her Audit Activity Reports are the best tool to have in your toolkit to level the playing field shared by facilities and these gargantuan MA plans.

Other segments will include these instantly recognizable broadcast features:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
• Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will substitute for Matthew Albright to report on current healthcare legislation.

DRG validation denials by Medicare Advantage (MA) plans have become a widespread and increasing concern for many hospitals.

But these denials may be the result of a misapplication of standard diagnostic criteria by a reviewer. Now, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is turning the DRG validation denials back on MAs. The OIG recently published several diagnosis-validation audits of MAs and recommended recoupment for exactly the same diagnoses the MAs have denied for providers.

But what can we learn from these audits to help manage diagnosis denials by payers? Does this portend new MA tactics? Sitting in for Dr. Ronald Hirsch during the next edition of Monitor Mondays will be our own physician and attorney, Dr John K. Hall, who will offer his take on the future of diagnosis denials and how to prepare.

Other segments will include these instantly recognizable broadcast segments:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors;
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment;
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH; and
• Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!

In today's episode, Mary explains the importance of Nuclear Medicine & PET Coder.  Listen in to find out why this textbook could be a great addition to add to your essential library.

While the pandemic may have shielded healthcare providers from intrusive recoupment audits, the auditing break was but temporary. Starting in August of 2021, UPIC, TPE, RAC and other audits started back up and the contractors had a lot of catching up to do. At the same time, the administrative law judges were under enormous pressure to get the backlog of cases completed by the end of 2022. The result? A paradigm shift in how hearings were conducted and the impact that has on outcomes. 

Senior healthcare analyst and RACmonitor correspondent Frank Cohen will talk about how these changes have benefited providers in getting judges to vacate the extrapolation estimates.  

Other segments will include these instantly recognizable broadcast segments:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will substitute for Matthew Albright to report on current healthcare legislation.