Using artificial intelligence (AI), along with an uncanny ability to misinterpret rules, Medicare auditors – specifically, third-party auditors of Medicare Advantage (MA) plans – are ever-ready to pounce on healthcare providers. And too often, it’s like shooting fish in a barrel.

The recent posting of three final rules will give auditors ample opportunity to search for more inadvertent errors on Medicare claims. Last week, as reported by RACmonitor, the Centers for Medicare & Medicaid Services (CMS) posted final rules on the same day for the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS), and the Home Health Prospective Payment System (HHPPS).

More rules = more audits.

It’ll be the area of focus during the next edition of Monitor Mondays, which will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• Special Report: RACmonitor investigative reporter Edward M. Roche will continue with the second installment in his three-part series that for the first time is showing how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims.
• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
• Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the latest healthcare regulatory news coming out of Washington, D.C.
• 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.

The next three consecutive Monitor Mondays broadcasts will constitute an explosive series, exposing for the first time how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims.

Learn about this outrageous behavior when RACmonitor investigative reporter Edward C. Roche presents the first edition of his three-part series that exposes wrongdoing that is penalizing providers and threatening their financial stability.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
  
  
• RAC Report: 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, D.C.
  
  
• 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.

Operating with virtual impunity, while relying on artificial intelligence, payor auditors have locked on to providers to deny claims that trigger audits.

Acts of omission by providers are often deemed acts of commission in the eyes of auditors – and the audits often lead to recoupment. Even the slightest apparently innocuous action can trigger a cascade of negative reactions, including denials.  Even knowing of misconduct is a major problem. During the next live edition of Monitor Mondays, healthcare attorney and physician John K. Hall will continue his two-part series on the consequences of seemingly inconsequential errors, and “fraud” that could very well just be the byproduct of other actions.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including::

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• RAC Report: 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, D.C.
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. 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.

Once suspended by COVID-19, claim audits are now back on the frontburner – Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Medicare Administrative Contractor (MAC) audits, plus Targeted Probe-and-Educate (TPE) audits are the new (or renewed) normal. It’s open season on providers, which is why, in large measure, the next live edition of Monitor Mondays will feature reports on how audits now being conducted by governmental and third-party contractors are making America “Audit Nation.”
Monitor Mondays will have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Physician and attorney John H. Kall, substituting for Dr. Ronald Hirsch, will make his Monday Rounds, but also will begin a two-part series exploring the landmine liability faced by utilization management (UM) and compliance professionals. Hall is the founder of Aegis Consulting Services.
• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Court Report: Famed whistleblower Mary Inman, partner at the law offices of Constantine Cannon, will report on the $25 million Medicaid fraud settlement in Massachusetts, the largest ever in the Bay State.
• 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, D.C.
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. 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.

Big surprise. But not really.

The Interim Final Rule (IFR) for the federal No Surprises Act, released last month, appears to offer bad news for out-of-network providers (OON), which does not come as a surprise to heathcare attorney Thomas Force, who will return to the Monitor Mondays broadcast.

Force will explain, citing that the guidance is focused on what the bill defines as good-faith estimates for uninsured and self-pay patients, along with the Independent Dispute Resolution (IDR) process between providers, facililies, and health plans. Force contends that the IFR has left many questions unanswered, and appears to be written for the benefit of health plans and carriers. Listen during the next live edition of Monitor Mondays, when there will be new light shed on a simmering old issue: providers versus payors.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• RAC Report: 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, D.C.
• SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. 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.

The heat is on.

As reported by RACmonitor, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) auditor, has started sending out documentation requests for short-stay inpatient audits. For targeted hospitals, Livanta will select 30 inpatient admissions of Medicare beneficiaries whose length of stay (LOS) was either zero or one day within the prior three months.

So beware. And be prepared. For context on this development, Dr. John Zelem will report on the use of Occurrence Span Code 72 during the next live edition of Monitor Mondays.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• RAC Report: 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, D.C.
• SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. 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.

Rampant auditing by Medicare Advantage (MA) plans is a constant occurrence, with notable cases being reported weekly by RACmonitor. To wit: the recent U.S. Department of Justice (DOJ) filing of a complaint in intervention in a case against Independent Health of Buffalo, New York and its coding vendor, DxID. And there’s the recent case of Sutter Health and its $90 million settlement in a MA risk adjustment fraud case.

The DOJ even intervened recently in a consolidation of six whistleblower cases against Kaiser Permanente, alleging risk adjustment fraud. Providing context and clarity on this ongoing challenge during the next edition of Monitor Mondays will be Edward C. Roche, director of scientific intelligence for Barraclough New York LLC, who asserts sarsastically, “we have rhesus monkeys auditing people like MDs, who have spent years and years learning how to make medical decisions.”

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Crisis Standards of Care: Day Egusquiza, president of AR Systems, Inc., and a resident of Idaho, will have the latest update on the crisis-of-care rationing unfolding in Idaho, Montana, and Alaska, as the deadly Delta virus is ravaging the country. This is striking primarily the unvaccinated, who are flooding emergency departments, causing hospitals and health systems to buckle under the strain of too few beds and too few physicians.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. 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.

• DOJ and Medicare Advantage: Famed whistleblower attorney Mary Inman, partner in the law of office of Constantine Cannon, will report on the U.S. Deptartment of Justice filing a civil complaint against a data-mining company affiliated with a Medicare Advantage (MA) plan for allegingly cheating the government out of tens of millions of dollars, thus enabling the plan to overcharge for treating patients.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
  
  
• RAC Report: 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, D.C.
  
  
• 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.

Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not present.

Reporting on these all-too-common and unwelcomed clinical validation denials will be Erica Remer, MD, a special guest during the next live edition of Monitor Mondays.  Dr. Remer, a member of the ICD10monitor editorial board, is also the popular co-host of Talk Ten Tuesdays, the long-running Internet radio broadcast produced by ICD10monitor.

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return 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.
• 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, D.C.
• 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.
• SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.

They take no breaks.

Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trusted weekly news and information Internet radio broadcast.

Featured updates from well-respected Monitor Mondays consultants include the following:

• Lead Story: Famed whistleblower attorney Mary Inman, partner at Constantine Cannon, will report on the second-largest Medicare Advantage fraud settlement under the False Claims Act (FCA). California’s Sutter Health will pay the government $90 million for allegedly submitting inaccurate and unsupported medical information on tens of thousands of patients.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return 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.
  
  
• 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.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.