Direct or indirect past affiliation with an individual the Centers for Medicare & Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare.

The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, waste, or abuse.

Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates. Mr. Wachler also discusses what constitutes an “affiliated entity” and what events must be disclosed.

Other segments to be featured on the broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• Court Report: Famed whistleblower attorney Mary Inman reports on Tenet Healthcare’s proposed $66 million False Claims Act settlement. Inman is a partner in the London office of Constantine Cannon.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducted the Monitor Mondays Listener Survey.
   
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Giant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable.

The results of a study published last week by Science revealed what researchers identified as a "significant racial bias" in Optum’s algorithm, which reportedly undervalues the healthcare needs of black patients. Although Science didn’t mention Optum by name, other news organizations have confirmed that it was, indeed, Optum.

Reporting on this developing story during this edition of Monitor Mondays is RACmonitor investigative reporter and New York attorney Edward Roche, director of business intelligence for Barraclough New York LLC.

Other segments to be featured on the broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports on the status of the Medicaid lawsuit in which more than two dozen Virginia behavioral healthcare providers had their managed care contracts terminated by six managed care organizations (MCOs). Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• Ring of Fire: Dr. Alvin Gore, the physician advisor at St. Joseph Health in Santa Rose, Calif., reports on disaster planning in the wake of horrific wildfires burning out of control in Northern California. Shortages of nurses who were ordered to evacuate is one of the many emergencies he continues to monitor as the fire rages.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on a trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
  
  
• Monday Rounds: Substituting for Dr. Ronald Hirsch, is Dr. Howard Stein, associate director of medical affairs and physician advisor in care management at CentraState Medical Center in Freehold, New Jersey. 

A federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings. The Centers for Medicare & Medicaid Services (CMS) could appeal the court’s decision on its site-neutral payment rule for hospital outpatient services. Score one for hospitals, but the war is far from over.

Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.

Other segments to be featured on the broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• E&M Coding Changes: Impending evaluation and management (E&M) changes for 2021 and their impact on coding and compliance professionals is reported by Shannon DeConda, founder and president of NAMAS.
  
  
• Monday Focus: Ransomware: Healthcare news has been rife with stories of bad actors from overseas planting ransomware in the business systems of hospitals and medical practices large and small. Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, reports on this ongoing problem and offers advice providers can take to mitigate the risk of global hackers.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Acts of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American Hospital Association (AHA) and the Federation of American Hospitals.

Reporting on this developing story during this edition of Monitor Mondays is former CMS official Matthew Albright, chief legislative affairs officer for Zelis Healthcare.

Other segments to be featured on the broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• War on Drugs: Famed whistleblower attorney Mary Inman, partner at the London law office of Constantine Cannon, reports that major drug manufacturers and distributors are proposing deals that could be worth up to $50 billion to help resolve the nationwide litigation of the pharmaceutical industry’s liability for America’s opioid crisis.
   
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
  • Resources from Ellen Success over Stress, DePaul University Grant, Robert Wood Johnson Foundation Grant to Purpose Built Communities, CVS Funding
• Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his trademark segment in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

There have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS): the Patient-Driven Payment Model.

Reporting on these new changes during this edition of Monitor Mondays will be Toby S. Edelman, senior policy attorney for the Center for Medicare Advocacy. The new PDPM system reverses the financial incentives that existed for 20 years. Instead of paying more money for more minutes of therapy that a resident at a SNF receives, the new system pays less for residents who receive therapy. Ms. Edelman will discuss how the reimbursement system has changed, and what residents and their families can do to try to ensure that patients continue to receive medically necessary therapy.

Other segments to be featured on the broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• Washington Report: President Donald Trump’s recent executive order tweaking the Medicare system continues to roil healthcare stakeholders. Reporting on the ongoing fallout is Matthew Albright, chief legislative affairs officer for Zelis Healthcare and former CMS official.
  
  
• Monday Focus: New York attorney and RACmonitor investigative reporter Ed Roche returns to the broadcast to report on the use of artificial intelligence in Medicare audits, as announced in the President’s executive order.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his trademark segment, in which he reports on problematic issues facing providers. HHS Proposes Stark Law Anti-Kickback Statue Reforms
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.   Medical Conservative

The Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program.

How will the information gathered by CMS be used, moving forward? And why is this action being taken by CMS? The agency has a history of attempted cuts to 340B reimbursement; the most recent such action by CMS occurred last December, after which a federal judge ruled against the move.

Reporting our lead story during this edition of Monitor Mondays is Maureen Testoni, president and CEO of 340B Health.

Other segments featured on this episode include:

• Court Report: Federal law enforcement personnel recently took down a fraudulent scheme involving 35 defendants associated with telemedicine companies and cancer genetic testing laboratories. The defendants have been charged for their alleged participation in fraudulently billing Medicare more than $2.1 billion for CGx tests. Reporting this story is famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon.
  
  
• RAC Report: Healthcare attorney Knicole Emanuel reports on the latest audits by Recovery Audit Contractors (RACs) and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), has the latest news on this trending topic that is attracting significant media attention. Ellen also conducts the Monitor Mondays Listener Survey.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays to report on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

As expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause.

The suit was filed by the Potomac Law Group.

During this edition of Monitor Mondays, healthcare attorney Knicole Emanuel, a partner in the aforementioned law firm and a member of the RACmonitor editorial board, provides an update on the lawsuit as it makes its way through the court system.

Also covered in this edition of Monitor Mondays:

• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
  
  
• Monday Focus: A listener reports that Noridian (Jurisdiction F), rather than providing any diagnosis codes for non-dialysis usage, insists on having five scenarios provided in order to determine if an order meets guidance criteria. Attorney and physician Dr. John Hall weighs in on this topic, which seems to have entangled front desk staff, schedulers, and physicians.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Other segments to appear during the live broadcast include the following:

• RAC Report: Healthcare attorney Knicole Emanuel reports our lead story on the mass terminations of behavioral healthcare providers in Virginia. Emanuel has also been at ground zero in Richmond this past week, representing the aforementioned association there. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listener Survey.
  
  
• Monday Focus: Physician advisors should spend their time talking to doctors, not reviewing records and writing lengthy status determinations, according to Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., returns to the broadcast to report on the consequences that arise when internal physician advisors merely sit behind their computer screens, to the exclusion of interactions with other physicians.
   
• Risky Business: Healthcare attorney David Glaser continues his reporting on the dramatic and long-awaited outcome of the recent court decision involving AsceraCare – a decision that appears to make it difficult to make a False Claims Act case based on physician judgment.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM). Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to avoid a Recovery Audit Contractor (RAC) audit. 

Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel. 

Other segments to appear during the live broadcast include the following:

• CMS Report: The Centers for Medicare & Medicaid Services (CMS) is cracking down on bad actors: past and present fraudsters. Author, educator, and consultant Duane Abbey, president of Abbey and Abbey Consultants, Inc., reports on CMS efforts to identify those who are or have been affiliated with illegitimate providers.
  
  
• Surprise Balance Billing: While it once appeared to be a done deal leading into the August recess for members of Congress, legislative action on surprise balance billing has stalled out as stakeholders and lawmakers struggle with the details. An update on this now-contentious issue is presented by Matthew Albright, chief legislative affairs officer for Zelis Healthcare and former CMS official.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SdoH), has latest news on this trending topic that is attracting significant media attention. 
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Do you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)?

You need to know because the Recovery Audit Contractors (RACs) and other contractors are reviewing SNF referrals. Reporting our lead story is physician and attorney John K. Hall, founder of the Aegis Firm. Hall reviews such statutory and regulatory requirements while also making recommendations for audit readiness.

Other segments to appear during the broadcast:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report the latest audits by RACs and other third-party auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• Hurricane Watch: Dr. Daniel Zirkman, the chief physician advisor at CarolinaEast Medical Center in New Bern, N.C., reports on how his facility prepared for Hurricane Dorian, which forced the mandatory evacuation of nearly 400,000 residents in that state. 
  
  
• SDoH Report: Marvin D. Mitchell, Director of Case Management and Social Services at San Gorgonio Memorial Hospital in Banning, Calif., east of Los Angeles, reports on how to operationalize social determinants of health (SdoH) concepts.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.