Monitor Mondays

Like fine wine, problem lists age very well. Too well, in fact.

Such lists can remain in place for months, even years, without being updated. And questions can lead to conflicts and errors.

Too often, problem lists simply languish, with unchanged patient encounter information. Moreover, even when a problem does appear on the problem list, it doesn’t necessarily signal that the provider addressed the issue during the patient encounter.

During the next live edition of Monitor Mondays, Dr. Andrew Markiewitz, a physician advisor and member of the RACmonitor editorial board, will delve deep into the root causes of problems in the problem list.

Other segments will include the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
  
  
• 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.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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, a legislative analyst at Zelis, will report on current healthcare legislation.

With the growth of Medicare hospice services comes expanded oversight on claims and care quality. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has initiated a nationwide audit of hospice claims on the heels of multiple in-depth audits of such facilities. Unified Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) have joined the hunt in recent weeks, putting all hospices on notice that vigilant compliance measures are essential. At the same time, there have been increased survey frequency and expanded sanction risk targeting these providers – and all of this will be part of the coverage of our lead story during the next Monitor Mondays broadcast. 

 Other segments will include the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs). 
  
  
• 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.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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 at Zelis, will be substituting for Matthew Albright, chief legislative affairs officer for Zelis, and will report on current healthcare legislation.

How is one major hospital system reducing observation hours?

Listen to the next live edition of Monitor Mondays to find out; that’s when Mary Beth Pace will return, by popular demand, to continue her compelling discussion on how she and her team at Trinity Health are taking steps to reduce the volume of observation hours. With her laser focus on patient care, Pace will report on how the Centers for Medicare & Medicaid Services (CMS) two-midnight rule, implemented in October 2013, continues to be misinterpreted by some insurance companies to their advantage, further obfuscating patient status determination.

Pace will also discuss what should be done with payers who dictate billing status, regardless of the care provided.

Other segments will include the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs). 
  
  
•  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.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.

What are your observation volumes doing to your bottom line? How much care do these patients get compared to your inpatients?

If your facility is like most facilities, the billing status does not dictate the care provided; it just dictates the reimbursement you can expect to obtain. Worse yet, it does not leverage the patient’s insurance benefits correctly. 

Join us during the next live edition of Monitor Mondays as Mary Beth Pace reports on what should and could be done with the insurance companies that are dictating billing status, no matter the care provided to their card holders. Listen and learn as Pace discusses how her organization is taking on this mission to care for patients.

Other segments reported by an array of trusted subject matter experts will include the following:

• 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.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.

The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center.

Great topics. Great analysis. More great educational opportunities now await you. So now get everyone on your team Front and Center.

Use code FRONTANDCENTER  for 15% off your RACmonitor webcast purchases.

Too many times, and in too many cases, providers are being subjected to flaws in methodologies and calculations used by auditors that lead to recoupment demands and other penalties.

Aided by ambiguously written rules from the Centers for Medicare & Medicaid Services (CMS), unscrupulous auditors are often able to pounce on unsuspecting providers, wreaking havoc on revenues and human resources. The toll can be devastating. Monitoring on a daily basis providers’ concerns and questions, RACmonitor and Monitor Mondays both report on these cases, bringing to light auditors’ errors of commission and omission.

During the next live edition of Monitor Mondays, trusted subject matter experts will report on the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
  
  
• The Whistleblower Report: Famed whistleblower attorney Mary Inman will report that the U.S. Department of Justice (DOJ) is joining a whistleblower lawsuit against Modernizing Medicine and a co-founder, alleging violations of the False Claims Act involving the company’s electronic health records (EHR) and kickbacks to physicians. 
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
  
  
•  SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will return to the broadcast to report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned.  

However, there are also so-called “technical denials,” in which real or alleged provider lapses in the prior authorization process arise that can be hard, or even impossible, to overcome.  During the next live edition of Monitor Mondays, Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in Banning, Calif., will report on this emerging audit trap, and also discuss how to avoid or overcome these crafty insurer maneuvers.

Other segments reported by an array of trusted subject matter experts will include the following:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs). 
•  Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
•  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 analyst for Zelis, will report on current healthcare legislation.
•  SDoH Report: Lenel James, business lead for the Blue Cross Blue Shield Association, will report on the news that’s happening at the intersection of healthcare regulations and the social determinants of health (SDoH). Mr. James will be substituting for Tiffany Ferguson.

Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fruit to be ripe for harvesting.

While the Centers for Medicare & Medicaid Services (CMS) continues to punish providers for claims submitted with errors of omission, the same disciplinary action is infrequently demonstrated publicly against payors behaving badly. It’s little wonder, in today’s highly regulated healthcare environment, that the audit landscape is fraught with peril for providers. Most notably, Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly.

For the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays.

Learn from an array of trusted subject matter experts who will report on the auditing landscape, while explaining how to protect your facility from recoupment of revenue:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
  
  
• The Whistleblower Report: RACmonitor’s resident physician and attorney, Dr. John K. Hall, will report on the unusual verdict in the case of Sheldon versus Allegan Sales, LLC.
  
  
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
• 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 Analyst at Zelis Healthcare, will report on current healthcare legislation.
  
  
• SDoH Report: Lenel James, MBA, will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.

As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread,  telehealth gained a foothold in America’s healthcare system, but that too is being subjected to audits. Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly.

 It's a topic that needs to be followed closely. So for the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays. 

 As always, an array of trusted subject matter experts will report on the auditing landscape, and how to protect your facility from recoupment of revenue:

•  The Whistleblower Report: Famed whistleblower attorney Mary Inman will report on the$260 million settlement that pharmaceutical manufacturer Mallinckrodt ARD LLC has agreed to pay to resolve allegations it violated the False Claims Act by underpaying Medicaid rebates.
  
  
•  The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).
  
  
•  Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
  
  
•  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: Former Centers for Medicare & Medicaid Services (CMS) official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
  
  
•  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.

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.  

In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS), it states that generally, claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Uniform Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) may perform reviews based on evidence of potential fraud or gaming, and the Comprehensive Error Rate Testing (CERT) contractor may review a random sample for the purposes of estimating the Medicare improper payment rate. The RAs, however, are not listed as audit contractors allowed to audit these claims – nor should they be. So why are providers receiving audit requests for these services from their Recovery Auditors?

Reporting our lead story during the next live edition of Monitor Mondays will be Marcy Andersen, director of account management at SAI360.

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

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the RAs.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• 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: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.
• 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.