Monitor Mondays

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.

2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior. 

The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and does it change the potential for audit risk? 

Joining the next live edition of Monitor Mondays will be senior healthcare Frank Cohen, who will report the results of his study of more than 30,000 audits of office visit codes.

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

• 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.

In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims.

The decision is likely to have serious ramifications, to the tune of tens of billions of dollars. It’s been estimated that such MA overpayments in 2016 soared to more than $16 billion.

The bad news is that private payers like UnitedHealth must return overpayments. The good news is a possible payday for providers who surrendered billions of dollars to private payers.

Reporting our lead story during the next edition of Monitor Mondays will be prominent healthcare attorney Andrew Wachler, managing partner in the law firm of Wachler and Associates.

To learn more about the details of this recent ruling and its implications for providers (and payers), listen to the next live edition of the weekly Internet radio broadcast, coming your way on Monday, Aug. 23 at 10 a.m. EST.

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

• 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,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.

The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits.

Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the low-hanging fruit created when administrators, physician advisors, and case managers aren’t on the same page, putting hospitals at even greater risk for more denials, lower reimbursement, and longer lengths of stay. It’s a conundrum documented in a nationwide survey undertaken by Sound Physicians and reported on by Chris Shearer MD, MPH, chief medical officer in the organization’s Physician Advisor Services section.

To learn more about the extent of recent auditing activities, listen to the next live edition of Monitor Mondays, coming your way on Monday, Aug. 16 at 10 a.m. EST.

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

• 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.
• 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.

Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries.

Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn the extent of recent auditing activities, listen to the next live edition of Monitor Mondays, coming your way on Monday, Aug. 9 at 10 a.m. EST.

You’ll also learn about the extraordinary move by the U.S. Department of Justice (DOJ) to intervene in whistleblower lawsuits brought by Constantine Cannon against Kaiser Permanente, one of the nation’s largest managed care organizations (MCOs), which has been accused of knowingly submitting false claims for risk-adjusted payments to the Centers for Medicare & Medicaid Services (CMS). Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will return to the broadcast next Monday to report on 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 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.
• 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 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.

Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight. 

Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation. 

Adding insult to injury is a new ruling handed down by the 5th Circuit Court allowing the U.S. Department of Justice (DOJ) to dismiss a whistleblower’s False Claims Act (FCA) suit. What does this decision mean for whistleblower cases? And, more generally, what does it mean for whistleblower outsiders who do their own independent analyses and investigations to launch an FCA case? Famed whistleblower Mary Inman, partner in the London office of Constantine Cannon, will return to the Monitor Mondays broadcast this week with an exclusive report on 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 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.
• 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.
• 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.

The COVID-19 pandemic might have subsided somewhat, but in the eyes of the Centers for Medicare & Medicaid Services (CMS), it is anything but over, as the agency continues to treat providers as if it were still surging.

In order of priorities, CMS is starting to push Targeted Probe-and-Educate (TPE) audits, according to healthcare attorney Andrew Wachler. He reports that his firm is starting to see activity of this nature, noting that before the pandemic, there were more than 13,500 such audits, adding that the consequences can be severe if not handled properly.

Next on his agenda during the next live edition of Monitor Mondays, Wachler will discuss audits and a False Claims Act (FCA) case relating to the Provider Relief Fund. And looking ahead, Wachler will report on what he expects to see with potential audits, actions he expects to see in telehealth, and the various areas of telehealth that feature the greatest exposure. 

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.
• 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.
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will have the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.