Several hospitals have now received audit notices from the HHS Office of Inspector General (OIG) for COVID-related claims. The OIG has begun auditing hospitals to “determine whether Medicare paid hospitals for these inpatient claims in accordance with federal requirements.” Make no mistake, the OIG is auditing provider billing, not payment. The OIG is not auditing Medicare Administrative Contractor (MAC) performance, according to physician and attorney John K, Hall, MD. Dr. Hall who will return to Monitor Mondays to report this developing story.

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

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make 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.
  
  
• 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.

What percentage of administrative law judge (ALJ) decisions end up at the Medicare Appeals Council? What percentage of those decisions are reversed?

These are important questions asked by a reader in response to a recent article written for RACmonitor by Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement. Cohen, who has extensive experience as a subject matter expert in ALJ hearings, will look under the hood of the perpetual appeals machine, while sharing insight into the appeal process – describing how it is broken and why.

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

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return to make 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.
  
  
• 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.

They’re using text messages. They’re offering vaccination cards, and even COVID-19 testing. They’re scammers.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is currently warning that providers that charge impermissible fees must refund them, and ensure that individuals are not charged any sum at all, for the COVID-19 vaccine – along with warning of fraudulent telemarketing calls and even door-to-door visits. Of particular concern are scammers pretending to be COVID-19 contact tracers.

“Legitimate contact tracers will never ask for your Medicare number or financial information, or attempt to set up a COVID-19 test for you and collect payment information for the test,” the OIG notes on its website.

Just how prevalent are these scams? Reporting our lead story during the next live edition of Monitor Mondays will be RACmonitor investigative reporter Ed Roche, who was among the very first to report on contact tracers during the early stages of the pandemic, here on Monitor Mondays and RACmonitor.

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.

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.