Monitor Mondays

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.

According to the U.S. Department of Justice, pharmaceutical giant Biogen will pay $900 million to settle a lawsuit that alleged the company gave doctors kickbacks to encourage them prescribe its drugs. The settlement resolves a lawsuit filed and litigated by former Biogen employee Michael Bawduniak against Biogen under the qui tam or whistleblower provisions of the federal False Claims Act. Famed whistleblower Mary Inman will report this story during the next live edition of Monitor Mondays. Inman, reporting from her London office, is expected to provide details on the settlement.

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: Matthew Albright, chief legislative affairs analyst for Zelis, who will report on current healthcare legislation.

Beware of enforcement action by the Centers for Medicare & Medicaid Services (CMS) for noncompliance of the Hospital Transparency Rule which took effect January 2021. The rule requires hospitals to make public—in machine readable files—prices for certain items and services. Failure to comply could result in fines as in the case of two Georgia hospitals. Make no mistake. CMS is laying down the law. Reporting our lead story during the next live edition of Monitor Mondays will be Govind Goyal, Executive Vice President at Panacea Healthcare Solutions, and a subject matter expert on Hospital Price Transparency Rule.

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: Matthew Albright, chief legislative affairs analyst for Zelis, who 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 CT/MR Coder.  Listen in to find out why this textbook could be a great addition to add to your essential library.

Provisions in the newly enacted Inflation Reduction Act represent some of the most significant changes to the healthcare system that have taken effect in the past decade. Maureen Testoni, president and CEO of 340B Health, will review some of the new law’s drug pricing elements. They include provisions for Medicare to start negotiating the prices it will pay for certain drugs for the first time in the program’s history. How these drug pricing changes play out will affect the entire healthcare system, including the safety-net providers who already receive discounted prices on some prescription drugs.

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.
• The News Report: Dennis Jones, Patient Financial Services at Montefiore Nyack Hospital will report on the single payer proposal.
• 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: Folana Houston, assistant general counsel for Zelis, who will be substituting for Matthew Albright, will report on current healthcare legislation.

A national debate is raging across America involving providers and payers. The vexing issue is of medical necessity—and the search for consensus on a definition for this simple yet complicated issue. 

During the next live edition of Monitor Mondays, Tim Brundage, MD will set the table for a robust discussion. Also on the rundown, the growing presence of private equity firms in healthcare. Given that they see healthcare as an attractive target for its investments, could their laser focus on improving profit margins potentially cross the line into Medicare fraud? Famed whistleblower attorney Mary Inman will report on False Claims Act cases that the U.S. Department of Justice has and continues to pursue against private equity for such alleged practices.

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: 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 Peripheral & Cardiology Coder.  Listen in to find out why this textbook could be a great addition to add to your essential library.

The warning was shot across the bow of Medicare Advantage Organizations (MAOs). The U.S. Department of Health and Human Services (HHS) Office of Inspector (OIG), in a report to the Centers for Medicare & Medicaid Services (CMS) raised concerned that MAOs could be denying prior authorizations requests in an attempt to increase profits.

CMS agreed to the report and, on Aug. 3, issued new guidance on the appropriate use of MAO clinical criteria for medical necessity reviews along with numerous revisions.

Reporting on this developing story during the next live edition of Monitor Mondays will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital.

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: Substituting for Matthew Albright, will be Cate Brantley, legislative affairs analyst for Zelis. Brantley will report on current healthcare legislation.