With little in the way of reporting on the backlog of appeals at the Administrative Law Judge (ALJ) level, you could conclude that such hearings are on hiatus.

But that’s not the case, according to senior healthcare consultant Frank Cohen, who will be reporting the lead story during the next live edition of Monitor Mondays. Cohen, director of business intelligence at DoctorsManagement, is expected to report that while he had testified at four ALJ hearings in all of 2019-2020, he has already testified at four so far this year, with four more between now and June – all pertaining to cases from 2014-2015. Ask Cohen why the Recovery Audit Contractors (RACs) are to blame for the backlog – his answer will be one you may not expect.

Other segments to be featured during the live broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
  
  
• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Monday Rounds: Attorney and physician John K. Hall, MD, founder of the Aegis Firm, will be pinch-hitting for Ronald Hirsch, MD, who regularly makes his rounds on Monitor Mondays.

President Joe Biden’s roughly $2 trillion infrastructure proposal, called the “American Job Plan,” includes approximately $400 billion to expand access to home care and community-based services, including access to long-term care provided under Medicaid.

Reporting on the impact of this possible new fusion of funding during the next edition of Monitor Mondays will be William Dombi, president of the National Association for Home Care and Hospice. No stranger to broadast listeners, Dombi’s appearance comes at a time when the nation continues to grapple with the coronavirus pandemic, which in turn has illuminated the need for keeping those with the greatest risk potential for the deadly virus in a home-care environment.

Other segments to be featured during the live broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
  
  
• Legislative Update: Stanley Nachimson, former Centers for Medicare & Medicaid Services (CMS) career professional-turned-well-known healthcare IT authority, will report on two proposal rules posted by CMS.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

The initiative to vaccinate enough Americans to achieve herd immunity against the deadly coronavirus appears to be stalling – this in the face of increases in infection rates.

According to data from the Centers for Disease Control and Prevention (CDC), the country has experienced an average of 65,000 new cases in the last seven days. Reporting our lead story during the next edition of Monitor Mondays will be John Foggle, MD, who returns to the broadcast following his stint as a frontline physician caring for COVID-19 patients at Rhode Island’s alternative site field hospital as a member of Brown University’s emergency medicine department. Dr. Foggle has a distinguished career in medicine, particularly as it relates to his being a consultant with the World Health Organization (WHO) in Fiji and Tonga at the global outbreak of the virus in late February and early March 2020, designing guidances and conducting healthcare worker training in preparation for COVID-19.

Other segments to be featured during the live broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  • Resource: https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/cardiology/QRG-Cardiology-Notification-Program-for-Commercial-Plans.pdf

“Ridiculous denials are frustrating. Vent, and then respond,” Dr. Andrew Markiewitz advises. “But ask: are you arguing over the Titanic’s deck chairs?”  

“Insurers may correctly identify unsubstantiated diagnoses,” Markiewitz added – and, if their findings are legitimate, return the money. If the DRG or reimbursement doesn’t materially change, after all, where’s the value?

Fighting the fight worth fighting will be the topic of the next edition of Monitor Mondays, when Markiewitz, a physician advisor at the Cincinnati-based TriHealth, Inc., will share his experiences in appealing DRG denials.

Other segments to be featured during the live broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Healthcare data breaches and the possibility of sanctions from the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) are a rightfully terrifying possibility for healthcare administrators.

But one hospital, MD Anderson Cancer Center, recently fought back and won. Reporting on the outcome of the decision handed down by the 5th Circuit Court of Appeals during the next live broadcast of Monitor Mondays will be Dr. John K. Hall, a physician and attorney. Hall, founder of the Aegis Group, will provide an analysis of the case, while offering valuable lessons that can be learned from it.

Other segments to be featured during the live broadcast include the following:

• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment. 
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

Now that the auditing reset button has been pressed, you and other providers can expect a torrent of audits and recoupments. In this new aggressive auditing environment, propelled by commercial as well as governmental auditors, providers must continually update their approach in response.

Against this chaotic background, there’s a new legal approach to audit defense advocated by Wachler & Associates. During the next live edition of Monitor Mondays, prominent healthcare attorney Andrew Wachler, managing partner at Wachler and Associates, will report on the latest legal theories, based on recent case law, to respond to technical and other audit denials.

Other segments to be featured during the live broadcast include the following:

• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
  
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

“Are your CFOs agitated by the increase of outpatients in inpatient beds because of the removal of total knee arthroplasty (TKA), total hip arthroplasty (THA), and hundreds of other procedures from Medicare’s Inpatient-Only List (IPO) list?” asked Julie Collins recently on the RAC Relief listserv. “If the surgeon’s office is securing the prior authorization, how are they doing with securing the proper classification (inpatient/outpatient)? Are they using a dartboard to determine which classification they request?”

During the next live edition of Monitor Mondays, Collins, manager of utilization management at TriHealth in Cincinnati, Ohio, will report on how her healthcare system is addressing this crucial issue.

Other segments to be featured during the live broadcast include the following:

• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

Changes to the nation’s Medicaid program, which reportedly covers some 70 million people, are expected soon. According to news reports, among the looming changes is the elimination of the work requirement for Medicaid recipients.

This will mark the featured topic during the next live edition of Monitor Mondays, when healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report on this change and others that will affect providers.

Other segments to be featured during the live broadcast include the following:

• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will report the Monitor Mondays lead story.

After all this time, you could still be doing it wrong when it comes to Condition Code 44.
If your hospital has been following the Medicare Condition Code 44 process associated with 42 CFR 482.30 because policy issued by the Medicare Advantage or commercial plans with which you’re contracted dictates its use, this may be the case, according to Dr. Juliet Ugarte Hopkins, the special guest during the next live edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

• Legislative Update: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report. 

With the purchase by UnitedHealthcare (UNC) of Change Healthcare, providers are contemplating notable differences between two sets of quidelines. Change Healthcare owns InterQual criteria, while UHC has traditionally used MCG criteria.

Becoming familiar with the variances in terms of observation timeframes, screening methodologies, severity of illness thresholds, and intensity of service thresholds for levels of care will be the topic reported on by Kelvin Valera, MD, a healthcare consultant and physician advisor, during the next edition of Monitor Mondays.

Other segments to be featured during the live broadcast include the following:

• Social Determinants of Health: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the latest news that’s occurring at the intersection of healthcare and socioeconomics. Ellen will also conduct the Monitor Mondays Listeners Survey.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
  
  
• Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report that the pharmaceutical company Roche and Medicare Advantage insurer Humana have agreed to pay $12.5 million to the U.S. government to resolve allegations that the companies violated the anti-kickback statute – marking the first False Claims Act (FCA) settlement resulting from a pharmaceutical company’s alleged payment of kickbacks to a Medicare Advantage Organization.