Monitor Mondays

With the purchase by UnitedHealthcare (UNC) of Change Healthcare, providers are contemplating notable differences between two sets of quidelines. Change Healthcare owns InterQual criteria, while UHC has traditionally used MCG criteria.

Becoming familiar with the variances in terms of observation timeframes, screening methodologies, severity of illness thresholds, and intensity of service thresholds for levels of care will be the topic reported on by Kelvin Valera, MD, a healthcare consultant and physician advisor, during the next edition of Monitor Mondays.

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

• 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.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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.
  
  
• Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report that the pharmaceutical company Roche and Medicare Advantage insurer Humana have agreed to pay $12.5 million to the U.S. government to resolve allegations that the companies violated the anti-kickback statute – marking the first False Claims Act (FCA) settlement resulting from a pharmaceutical company’s alleged payment of kickbacks to a Medicare Advantage Organization.

To ensure compliance in conveying device credits and to identify providers who do not, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has a specific Annual Work Plan item to address the matter.

Either through targeted device credit audits or enveloped in broader general billing compliance regulations for hospitals and ambulatory surgical centers (ASCs), the OIG is clearly seeking to ferret out “noncompliers.” Adding fuel to the fire, the OIG also has a related Work Plan item based on device credits already reported, but done improperly: outpatient outlier payments for claims.

Reporting our lead story during the next edition of Monitor Mondays will be Michael G. Calahan, PA, MBA, AHIMA-approved ICD-10-CM/PCS trainer and vice president of hospital and physician compliance with HealthCare Consulting Solutions (HCS). Calahan will also reveal five critical mistakes providers often make in trying to comply with these stringent rules.

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

• 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.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.

Billions of dollars in overpayments are levied annually against healthcare providers by the Centers for Medicare & Medicaid Services (CMS), based on the use of extrapolation audits. And while thousands of extrapolation audits are completed each year, the targeted provider or organization most likely will appeal the use of extrapolation.
In nearly all cases, the appeal is focused on one or more flaws in the methodology used to create the sample and calculate the extrapolated overpayment estimate. But how do you uncover the flaws?


Reporting our lead story during the next edition of Monitor Mondays, with answers to that question and others, will be Frank Cohen, senior healthcare analyst and director of business intelligence at DoctorsManagment.

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

• 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.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.

Even as the nation continues to struggle with the coronavirus pandemic, President Joe Biden, who took office Thursday as the 46th President, signed executive orders mandating that masks be worn on federal property and for interstate travel on trains, transit systems, and airlines – this being part of the President’s agenda for the first 100 days in office. Meanwhile, shortages of the COVID-19 vaccine are being reported throughout the country, most notably in the Big Apple, where New York City Mayor Bill de Blasio reportedly said the city would exhaust its vaccine supply this week.

Reporting our lead story during the next edition of Monitor Mondays will be John Foggle, MD, a frontline physician caring for COVID-19 patients at Rhode Island’s alternative site field hospital as a member of Brown University’s emergency medicine department.

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

• Cyber Watch: Special Series: RACmonitor investigative reporter Edward Roche will begin a new series on Monitor Mondays, focusing on cyber security issues imperiling the U.S. In his first report, Roche will describe how New York City is a city in crisis when it comes to how it is confronting serious issues related to its massive vaccination program – it’s not working.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.

Most physicians are expected to see in an increase in payments from Medicare, thanks to the latest COVID-19 relief bill. But with good news always comes some caution.

First of all, the more that is paid, the more can be recouped during an audit. And with respect to provider compensation models that rely on relative value units (RVUs), it is possible that the increase in work RVUs may exceed the increase in the total RVUs – meaning that a provider may make more than what is proportional to overall practice revenue. This could have implications with respect to fair-market value, and should be watched very closely.

Reporting our lead story on this timely matter during the next live edition of Monitor Mondays will be Frank Cohen, senior healthcare analyst and director of business intelligence at DoctorsManagment.

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

• 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.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.

With the calamitous year of 2020 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future of America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system.

With so many major changes expected to take place in 2021, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of healthcare, both now and throughout a new year that has arrived amid a time of unprecendented uncertainty.

During the next edition of Monitor Mondays, host and RACmonitor Publisher Chuck Buck will have an all-star lineup of experts on hand to tell you what to watch out for, marking the 2021 premiere for the weekly Internet broadcast, which is celebrating 11 years of live programs.

Segments to be featured during the live broadcast include the following:

• 340B Health: The president and CEO for 340B Health, Maureen Testoni, is expect to report on a recent advisory opinion from the U.S. Department of Health and Human Services (HHS) General Counsel, saying that drug companies denying 340B discounts to hospitals using community-based pharmacies are wrong and should stop.
  
  
• COVID-19: Frontline physician John Foggle will provide a real-time update on the raging spread of the coronavirus, at a time when public health experts are predicting that the U.S. death toll could eclipse 450,000 by February.
  
  
• Home Health and Hospice: William Dombi, president of the National Association of Home Care and Hospice, will report on the impact of COVID-19 and the public health emergency (PHE) on his association’s members.
  
  
• IRF: One of the nation’s foremost authorities on inpatient rehabilitation facility (IRF) services, Angela Phillips will return to report on the resumption of reviews by Recovery Audit Contractors (RACs) on IRFs.
  
  
• The Special Report: Should medical record auditors be certified? RACmonitor investigative reporter Ed Roche will report on why he believes there is a need.
  
  
• 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 of the recently passed surprise billing law.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

Amid the chaos created by the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) released two major final rules this week: the 2021 Physician Fee Schedule and the Outpatient Prospective Payment System (OPPS), with the latter having been widely anticipated. Both final rules portend significant new regulatory changes for providers, patients, and payors. Given the gravity of these new changes, the next upcoming Monitor Mondays broadcast will encompass a special live open door forum to answer questions from listeners.

Segments to be featured during the live broadcast include the following:

• Court Report: Famed whistleblower attorney Mary Inman, partner in the London law office of Constantine Cannon, will return to the broadcast to report on three major whistleblower cases.
  
  
• COVID-19: Frontline physician John Foggle will provide a real-time update on the raging spread of the coronavirus — at a time when Centers for Disease Control and Prevention (CDC) Director Robert Redfield is predicting that the U.S. death toll from COVID-19 could eclipse 450,000 by February.
  
  
• Monday Focus: Utilization Review: Dr. John Zelem, founder of Streamline Solutions Consulting, Inc., will report on the role of utilization review amid the pandemic.
  
  
• Rural Health Report: The nation’s rural communities are reported to be ravaged by COVID-19. Leslie Marsh, the CEO for Lexingtion Regional Health Center, will report on how her facility is being impacted by the pandemic.
  
  
• The Special Report: Andrew Dombro, MD will report on the impact of COVID-19 on providers and patients engaged in chronic care management.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

A whistleblower recently exposed an alleged risk-adjustment scheme that was apparently designed to artificially inflate reimbursement provided under Medicare Part C, aka Medicare Advantage (MA).

The accompanying lawsuit alleged that GHC hired an outside vendor to review and “improve” its risk adjustment scores. According to the whistleblower, GHC submitted t

Reporting our lead story on this matter during the next live edition of Monitor Mondays will be Max Voldman, JD, an associate of Constantine Cannon.

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

• Special Report: Bereavement: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will don her case management hat to report on how hospital personnel are dealing with the death of patients in the wake of COVID-19, which has claimed the lives of more than 259,000 here in the U.S. 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.

The next upcoming Monitor Mondays broadcast will encompass a special live open-door forum, coming at the intersection of compliance and the coronavirus – a jarring combination, in light of the fact that the continuing viral pandemic has claimed the lives of more than 250,000 and infected more than 11 million in the U.S.

It is here, at this critical point, that providers are reconciling a patchwork of regulatory waviers while addressing the urgent need of helping patients in their struggle to survive. Adding a layer of complexity is the spectre of audits and the ever-watchful eye of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

In recognition of the confusion, the next edition of Monitor Mondays will also be extended to 60 minutes, allowing for questions and answers.

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

• OIG Report: RACmonitor investigative reporter Edward Roche will report on the latest move by the OIG that faults Medicare contractors for being inconsistent in their review of extrapolated overpayments amid the appeal process.
  
  
• COVID-19: Frontline physician John Foggle will return to the broadcast to provide a real-time update on the raging spread of the coronavirus – at a time of widespread holiday travel for Thanksgiving.
  
  
• Special Report: Andrew Dombro, MD will report on the impact of COVID-19 on providers and patients engaged in chronic care management.
  
  
• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.
  
  
• RAC Report: Attorney Ashley Thomson, 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 status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.

There has recently been, as some might suggest, the luxury of taking a brief hiatus from medical record audits.

But that was then, and this is now.

Because now is the time to prepare, assess timeframes and provider requirements, and ensure that a proper compliance plan is in place. Certainly, audits are a growing source of concern, but there is no need for panic when adequately prepared, as you’ll learn from Susan Gatehouse, founder and CEO for Axea Solutions, who will be the special guest during the next live edition of Monitor Mondays.

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

• 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making 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 status of healthcare legislation associated with the current COVID-19 pandemic.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of COVID-19 and the SDoH. Ellen will also conduct the Monitor Mondays Listeners Survey.