Monitor Mondays

The Government Accountability Office (GAO) is recommending expansion of the Medicaid Recovery Audit Contractors (RACs) program, to include auditing of payments made to managed care organizations (MCOs), according to a GAO report released in June.

Launched in 2011 as a consequence of the Patient Protection and Affordable Care Act (PPACA) by the Centers for Medicare & Medicaid Services (CMS), the Medicaid RACs were purported to be aggressive in their recouping of alleged Medicare Fee-for-Service (FFS) overpayments. They could now be poised to expand into the rapidly growing MCO plans.  

During the next live edition of Monitor Mondays, Dennis R. Jones, senior director of revenue cycle at Jefferson Health, will report on this developing story.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.

There is a buzz swirling within the healthcare auditing community. And thanks to RACmonitor investigative reporter Edward M. Roche, the news is buzzworthy.

According to Roche, a legal team has developed two arguments that can be used by healthcare providers in federal court after the Administrative Law Judge (ALJ) process is completed. One argument is based on constitutional rights, while the other is a contradiction between the Medicare Program Integrity Manual and adopted federal law.

During the next live edition of Monitor Mondays, Mr. Roche will discuss these two arguments briefly, and issue a call for providers who are at this stage in their appeals and might be interested in someone taking up their case on a contingency basis. 

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make 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, state legislative affairs analysis for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to remedy Medicare Part B pay cuts made to 340B hospitals by issuing a lump-sum repayment to affected facilities.

Last year, the U.S. Supreme Court ruled that those cuts, implemented by CMS from 2018 through most of 2022, were unlawful. Consequently, CMS proposed to offset the refunds by reducing payments for non-drug services to all hospitals under the 2024 Outpatient Prospective Payment System (OPPS). Commenting on this latest development impacting 340B hospitals during the next edition of Monitor Mondays will be the president and CEO for 340B Health, Maureen Testoni.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make 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 analysis for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Although the 21st Century Cures Act was enacted in 2016, many hospitals today continue to struggle with effective implementation of its provisions and the goal of preserving patient access to medical records.

Seven years later, however, meaningful guidance regarding its enforcement is here. One of the provisions requires developers not to engage in information blocking.

Now that the guardrails are in place and the risks have been identified, Monitor Monday’s own physician and attorney Dr. John K. Hall will review the related enforcement actions and the penalties during the next live edition of the long-running Internet broadcast.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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, a legislative analyst for Zelis, will report on current healthcare legislation.

At least 1.3 million Medicaid enrollees have been disenrolled as of June 20, according to the Kaiser Family Foudation (KFF) “Unwinding Tracker.” This estimate could be an under-count, KFF admits, due to state recordkeeping details. Yet the major issue looms on the horizon: what will happen to those who have lost their Medicaid benefits? Could a tsuansmi of patients without health insurance soon appear at your hospital?

During the next live edition of Monitor Mondays, Tony DiLuca, principal at Physician and Tactical Healthcare Services, LLC (PATHS) and a member of the Pennsylvania Department of Health and Human Services (HHS) Fee-for-Service Subcommittee, will report on the unwinding process of the enrollment, along with current updates and best practices.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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, a legislative analyst for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

“Hospitals may be the most complex organizations in the world,” writes Edward M. Roche, scholar, United Nations consultant, and RACmonitor investigative reporter. “They are tasked with improving patient outcomes, controlling costs, and meeting sustainable environmental goals.”

Roche, who will be the featured panelist during the next live edition of Monitor Mondays, believes that hospitals, in their quest for stability, have been nonetheless traumatized by the COVID-19 epidemic and a suffocating regulatory environment. Roche will also report on how many American hospitals now are in the midst of a digital transformation that is leading to an era of “smart hospitals” that will deliver unparalleled integration and improvements in all aspects of healthcare.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare & Medicaid Services (CMS), U.S. Department of Justice (DOJ), and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) have increased audits to reduce improper payments, using predictive modeling and artificial-intelligence (AI) tools. Risk-based audits rose by 28 percent and prospective audits by 32 percent in 2022.

To ease the burden on revenue cycle management (RCM) teams, a combination of automation, analytics tools, and denial management software can be used for hybrid audits, reducing denials and increasing reimbursements. During the next live edition of Monitor Mondays, Ritesh Ramesh, CEO for MDaudits, will report on how, by leveraging people and technology, internal audits can be conducted faster, errors caught earlier, and staff can focus more on training and optimizing revenue.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday rounds.
  
  
• The RAC Report: Healthcare attorney Kyla Wonder, 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 officer for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

This week, a disgraced Elizabeth Holmes was seen in media clips walking in the company of two unidentified men. Evidently, Holmes, who was convicted of fraud for her blood-testing start up, Theranos, turned herself in at a minimum-security prison in Texas to begin an 11-year prison term.

All this media coverage raises the question: how easy is it to run afoul of the government regarding a wide range of statutes and regulations?

Moreover, how far do you have to go to actually get to prison? During the next live edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine some recent convictions and sentences to help you assess your risk – keeping in mind that there’s no parole from federal prison.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Bonney Olney, director of Level of Care Service for R1 RCM, will make her Monday rounds, substituting for Dr. Ronald Hirsch.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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.
  
  
• Legislative Update: Cate Brantley, JD, a legislative analyst for Zelis, will report on current healthcare legislation.
  
  

Why the confusion and the apparent uptick in denials by Managed Care Organizations (MCOs) for skilled nursing facility (SNF) transfers?

Returning to report on this vexing topic during the next live edition of Monitor Mondays will be Ben Kartchner, MD, a physician advisor who will join the broadcast to present the final installment in his two-part series being produced by RACmonitor and Monitor Mondays.

Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors, exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Mary Beth Pace, vice president of Trinity Health, will be making her Monday Rounds, substituting for Dr. Ronald Hirsch.
  
  
• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullen, 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.
  
  
• Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Medical necessity denials for skilled nursing facility (SNF) transfers by Managed Care Organizations (MCOs) are increasing at an astonishing rate.

The reason seems to be a lack of understanding of the difference between skilled and non-skilled care. During an exclusive two-part series being produced by RACmonitor and Monitor Mondays, Ben Kartchner, MD will delve into this complex topic that is generating buzz, especially among physician advisors, many of whom appear to be struggling with post-acute care (PAC) and, specifically, SNF services. In fact, Dr. Kartchner will be adapting his recent presentation to the American College of Physician Advisors exclusively for Monitor Mondays and RACmonitor. You will learn how to effectively counter MCO denials with newly gained knowledge from the broadcast, including the actual medical necessity requirements for SNF transfers.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, 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 Mullen, 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.
  
  
• Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.
  
  
• The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.