Monitor Mondays

SPECIAL GUEST
Edward Roche, JD, PhD
Director, Scientific Intelligence, Barraclough NY LLC

ALSO FEATURING
Matthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP;
David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQ

RACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant abuse directed at healthcare providers by overzealous (and, in some cases, incompetent) auditors.

Relying on scant evidence of actual fraud, the auditors, working in what Roche describes as a giant industry, deny claims while ignoring more the egregious cases of premeditated fraud and abuse. During the next live edition of Monitor Mondays, Roche will be calling for major reform of these auditing practices, claiming in an exclusive segment that the sprawling industry of coding experts, consultants, lawyers, and statisticians seldom catch the real perpetrators of fraud and abuse.

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,anationally 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.

Six major U.S. drug manufacturers are refusing to provide 340B discount pricing for outpatient drugs sold to safety-net hospitals, community health centers, and public health clinics when those drugs are dispensed in community pharmacies.

Will it take an act of Congress to intervene in this ongoing battle to restore 340B discounts and refund overcharges? Maureen Testoni, J.D., President and CEO of 340B Health, will bring us up to speed on this rapidly developing situation during the next live edition of Monitor Mondays. 

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.
• Billing Code 44: Physician advisor Andrew Markiewitz, MD will return to the broadcast to report on why getting Medicare inpatients into the correct status creates an administrative wrinkle: the dreaded billing Code 44.  

If your facility is considering submitting an amended claim request for a higher-weighted diagnosis-related group (HWDRG), be aware: the Centers for Medicare & Medicaid Services (CMS) has the authority to have your amended claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

And that alone could open up Pandora’s Box. Reporting our lead story during the next live edition of Monitor Mondays will be Susan Gatehouse, founder and CEO for Axea Solutions. Gatehouse, also a popular panelist on Talk Ten Tuesdays, will report on the possible consequences of such an action while providing guidance on how to ensure all your ducks are in a row.

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.
• 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.

There are lists upon lists of hospital rankings. But there’s one list you’ll certaintly want your hospital to avoid.
A report from Johns Hopkins University has revealed that many of America’s top 100 hospitals are using predatory tactics to pursue lawsuits against patients. Highlighting this list are government hospitals as well as nonprofit health systems called out for hounding patients to collect debt for services provided.

The Patient Protection and Affordable Care Act (PPACA), which survived a third challenge in the U.S. Supreme Court recently, specifically bars hospitals from engaging in this type of behavior.

“(This) may be a good time to relook at your financial assistance policy and ensure you are following appropriate guidelines according to the PPACA, particularly if your institution is a nonprofit,” says Tiffany Ferguson, who will report on the story during the next live edition of Monitor Mondays. “Remember that financial assistance is applied to all emergency and medically necessary care in the hospital facility.”

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.
• 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.

UnitedHealthcare is the latest insurer to join the growing lineup of payors that want to second-guess patients and deny payment for emergency department (ED) services after they’ve been rendered.

As reported here on Monitor Mondays last week, UnitedHealthcare plans to extend no coverage or limited coverage to ED claims, retroactively – including any claims the giant insurer deems non-emergent. Our own Dr. John K. Hall will report on this recent development during the next edition of the Monitor Mondays broadcast, offering tips on how to prepare for the consequences of these denials.

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.
• Court Report: Famed whistleblower attorney Mary Inman, partner at the London office of Constantine Cannon, will return to the broadcast to report on the latest wrinkle in the whistleblower lawsuit launched by Integra Med Analytics. The Department of Justice (DOJ) has intervened in one Integra case against 11 nursing homes.

Are your physicians providing detailed documentation as they adhere the 2021 Evaluation and Management (E&M) Guidelines? Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement, is concerned that they might not be – which, he believes, squarely puts them in an uphill battle, defending themselves from quality audits and potential malpractice suits. And Cohen has the numbers to back up his concerns, which he will share during the next live edition of Monitor Mondays.

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.
  
  
• 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.

There was a time when the word “logjam” seemed to be synonymous with the Administrative Law Judge (ALJ) hearings conducted under the purview of the Office of Medicare Hearings and Appeals (OMHA).

Today, by all accounts, hearings are being scheduled almost back-to-back, and attorneys are scrambling to represent their clients during unprecendented times. Preparing for a multi-million-dollar hearing on Tuesday, May 25 is Andrew Wachler, managing partner at Wachler and Associates – and the cases he’s working have dates of service dating back to 2009 and 2010. With a long-established presence at the ALJ level of appeal, Wachler will brief Monitor Mondays listeners on the new reality during the next edition of the weekly Internet radio broadcast.

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, 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.
  
  
• 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.

Resources: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000585.asp

“Incoming!” are the typical dreaded shouts heard from soliders hunkered down in bunkers when shelling begins.

Today, across America, you can hear the same cries when it comes to claims auditing. Audits are incoming. Third-party auditors, governmental auditors, even auditors from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) looking at COVID-related claims are incoming – and the onslaught is occurring in rural hospitals as well as big city health systems and teaching facilities alike.

Does this portend a future of escalating audits? During the next live edition of Monitor Mondays, an all-star lineup of audit and regulatory experts will come together in a 60-minute edition of the venerable weekly broadcast.

The live broadcast includes 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.
  
  
• Risky Business: Healthcare attorney David Glaser, a 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.
  
  
• The Court Report: Famed whistleblower Mary Inman, a partner in the London office of Constantine Cannon, will report on three notable whistleblower suits, all involving well-known healthcare brands.
  
  
• The Analysis: E&M 2021 Guidelines: Senior healthcare analyst Frank Cohen, director of business intelligence for DoctorsManagement, will report on his latest analysis of evaluation and management (E&M) 2021 guidelines for office visits; noteworthy will be his analysis of medical necessity audits.
  
  
• Utilization Management versus Utilization Review: Dr. John Zelem, founder of Streamline Consulting Services, will return to the broadcast to explain why utilization management and utilization review are not to be used interchangeably, yet they are, with increased frequency.
  
  
• Jab City, USA: Dr. John Foggle, Adjunct Associate Professor of Emergency Medicine at the Warren Alpert Medical School of Brown University, and an authority on the coronavirus will return to the broadcast to report on vaccine rates in the U.S. – as most experts warn that herd immunity is not likely to be achieved in the near future.
  
  
• Law and Order: Monitor Mondays’ own physician and attorney, Dr. John K. Hall, will report on the 11th Circuit Court of Appeals decision in the American College of Emergency Medicine versus Blue Cross and Blue Shield of Georgia. Understanding and applying the court's decision will help you and your team when faced with denials for services provided in your emergency department.

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.