Monitor Mondays

The U.S. Department of Justice (DOJ) reports that fraud against the U.S. under the federal False Claims Act (FCA) has amounted to $2.2 billion recovered in settlements and judgments for the 2022 fiscal year.   

As in past years, FCA recoveries in the healthcare and life sciences industries continued to dominate enforcement activity in terms of the number and value of settlements, with healthcare fraud cases comprising 80 percent of total recoveries. These involved a wide range of issues, including Medicaid fraud, unnecessary and substandard care, kickbacks, and Medicare Advantage (MA) fraud. 

During the next edition of the weekly Internet radio broadcast, whistleblower attorney and Monitor Mondays regular contributor and panelist Mary Inman will report on healthcare enforcement trends from 2022, including a record-breaking $266.4 million reward to the whistleblower who reached a $900 million settlement with Biogen for kickback allegations, 10 years after filing his qui tam case.     

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 & 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.

The concern is real. And it’s growing.

Providers could incur False Claims Act (FCA) liability when care that is delivered crosses over from “worth less” to “worthless.” You need to know where to draw the line. And that’s why we asked physician and attorney John K. Hall to explain, during the next live edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

• Special Report: Prominent healthcare attorney Andrew Wachler, managing partner at Wachler and Associates, will return to the broadcast to report on meeting the 90-day statutory timeframe for administrative law judge (ALJ) hearings.
  
  
• 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 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.
  
  
• 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.

What constitutes inpatient status? Should patient status be determined by guidelines or screening criteria? Or just the facts?

Revisiting what is certain to be considered an evergreen issue, Dr. Andrew Markiewitz will return to report the lead story for the next upcoming live edition of Monitor Mondays to continue discussing the vexing topic of patient status. Dr. Markiewitz is expected to report that screening criteria, scoring systems, and guidelines help determine medical necessity and patient status. But, he will add, although these metrics are used by payers, they are not treatment protocols. “We need to base our care on the patient in front of us,” advises Dr. Markiewitz.

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 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.
• Legislative Update: Folana Houston, a legislative analyst for Zelis, will report on current healthcare legislation.
• The Wrapper: Dr. John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

Healthcare providers nationwide are facing menacing interactions with auditors that, like hungry predators, are looking at submitted claims for the slightest evidence of omission or commission as the justification to pounce.

But it’s not so much the actual auditing as the long and wearisome journey of appeals – and the very real possibility of financial disaster. Although medical record auditing is not new, its frequency and alleged abuses contribute to a tell a tale of tragedy for America’s healthcare system.

That is why each and every Monday morning, Monitor Mondays has been alerting its listeners as to consequences of auditing gone awry – but also reporting on preventative measures providers can take to help their facilities avoid takebacks and fines.

This coming Monday, Monitor Mondays will continue with its reporting on auditors behaving badly.

That’s when listeners will hear of complication and comorbidity (CC) risk scores: a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care. 

Out of this model was born clinical documentation improvement, or CDI – a push to improve documentation so that it improves the reporting of diagnoses and procedures, thereby optimizing the scores. But with this comes the opportunity for abuse. 

So, can these risk scores help predict whether a provider is under-coding, over-coding, or coding optimally? 

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 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.
• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.
• The Cohen Report: Senior healthcare analyst Frank Cohen will file the second report in his two-part series on his research findings that Hierarchical Condition Category (HCC) risk scores could be used to negotiate Medicare Advantage rates.
• Livestream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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Never-before-seen data has revealed that Hierarchical Condition Category (HCC) risk scores could predict under- or over-coding – and it will be the primary topic of discussion during the next live edition of Monitor Mondays.

That’s when senior healthcare analyst Frank Cohen will report on his findings. The HCC risk score is a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care. 

Out of this model was born clinical documentation improvement, or CDI – a push to improve documentation so that it improves the reporting of diagnoses and procedures, thereby optimizing the scores. But with this comes the opportunity for abuse. 

So, can the HCC risk score help predict whether a provider is under-coding, over-coding, or coding optimally? 

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 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.
• Legislative Update: Cate Brantley, legislative analyst for Zelis, will report on current healthcare legislation.
• Livestream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

In May 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a report claiming that 25 percent of Medicare patients experienced adverse events during their October 2008 hospital stay.

“That’s a staggering number,” said John K. Hall, MD, in an email to RACmonitor. “So, what does it mean, and what should providers expect from other auditors and government agencies?”

During the next live edition of Monitor Mondays, physician and attorney Dr. Hall will review the report and offer suggestions to prepare if the OIG comes knocking at your door.

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 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.
• Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.
• LiveStream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual.

As the rest of the nation’s healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here and in RACmonitor.

Broadcast segments will include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds, during which he will report an exclusive auditing story in which he details news about a move by the Centers for Medicare & Medicaid Services (CMS) to clamp down on Medicare Advantage (MA).
• 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.
• Legislative Update: Cate Brantley, a federal legislative analyst for Zelis, will report on current healthcare legislation.
• Docs and Regs: Monitor Mondays’ own physician and attorney, Dr. John K. Hall, will report on how revisions to water down the Medicare Program Integrity Manual tend to increase liability for providers.
• Tip Sheet: RACmonitor investigative reporter Edward M. Roche will have another jaw-dropping story about audits, auditing, and a dismal outlook for 2023.
• Live Stream Chatting: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.

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