Monitor Mondays

The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe.

The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its features. For example, Medicare home health is moving quickly into the world of value-based purchasing. Beginning Jan. 1, 2023, all home health agencies will be subject to a national demonstration program that puts up to 5 percent of their revenue at risk by tying it to their patient care performance. Each home health agency will compete with all others to determine which providers get bonuses and which are financially penalized.

We’ll also report on the latest news and most current updates. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• 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.
• 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.

The auditing never stops, and the pace is quickening. New issues, new audits.

But what are the costs for hospitals seeking to avoid audits? In one of the most comprehensive reports of its kind ever offered, RACmonitor and Monitor Mondays will bring on board prescient thought leaders to define the contours of this deepening healthcare regulatory crisis. During the next edition of Monitor Mondays, our very own physician-attorney John Hall will report on the Centers for Medicare & Medicaid Services (CMS) vaccine mandate that almost happened, along withwhat this means, what you need to do, and, of course, how it might be audited.

The latest Comprehensive Error Rate Testing (CERT) report revealed more than $25 billion in improper payments. And that means that providers and suppliers will have their processes and documentation audited further. Former Recovery Audit Contractor (RAC) Medical Director Robert Glenn, MD will report on how RACs utilize similar techniques to identify audit targets.

What are the costs for hospitals trying to protect themselves from these audits? Maggie Shi, a PhD candidate at Columbia University, will share her doctorial thesis using mathematical modeling that may be beyond the comprehension of some.

We’ll also report on the latest national audit news updates from well-respected broadcast consultants, including:

• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
• 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.

"It’s time to stop getting stuck thinking we have a square-peg-and-a-round-hole problem, and focus on the fact that 42 CFR codifies and makes it law that a Medicare Advantage plan, even though it has autonomy in its contract, cannot offer less benefits than Medicare. Medicare Advantage plans cannot have more restrictive guidelines than Medicare; they must at the very least adhere to the simplistic confines of traditional Medicare” – this according to Dr. Jerilyn Morrissey, who will make her debut appearance during the next live edition of the long-running Monitor Mondays broadcast.

We’ll also report on the latest news and most current updates, offering you our early-warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

• RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return 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 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.

The signs are ominous. New final rules have been published. All the auditors are there, ready to pounce. Warnings are being sounded. It’s a tsumani of audits.

During the next live edition of Monitor Mondays, we’ll report on the latest news and most current updates, offering you our early warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including:

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

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.