Monitor Mondays

It’s that bright new shiny object few seem to manage to resist: artificial intelligence (AI).

Here at RACmonitor and Monitor Mondays, we have been reporting on how this disruptive technology has been altering the compliance landscape.

And we will continue that reporting. AI is rapidly reshaping healthcare auditing and compliance, and as organizations move toward greater claim visibility and AI-driven review processes, what does that mean for audit exposure, risk, and oversight? 

Join us during the next live edition of the venerable Monitor Mondays broadcast for an incredible journey, as Pam Warren explores how AI is changing the compliance landscape, and what organizations should be thinking about now. Warren, from AAPC, is the manager of regulatory billing audits for MaineHealth in Maine, the largest healthcare system in Northern New England.

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

·      Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Introducing FOCUS (Fraud Oversight through Careful Use of Statistics).  The U.S. Department of Justice (DOJ) has launched a new initiative in response to the surge in False Claims Act qui tam filings by data miners.

Today, roughly 45 percent of DOJ cases involve FCA data miners. You and your team will learn the inside story of this new initiative along with news of two significant data miner-initiated cases: a $6.73 million settlement against a California vascular physician who billed Medicare for unnecessary stent procedures at 30 times the national average; and a $300,000 settlement against three Illinois skilled nursing facilities that billed Medicare for unnecessary and inflated rehabilitation services.

Reporting this dramatic story will be whistleblower attorney and a partner in the New York office of Whistleblower Partners, Hamsa Mahendranathan. 

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

·      Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Healthcare compliance has entered the machine-learning era, and most organizations have not yet noticed. 

Providers are using artificial intelligence (AI) to generate documentation, surface reimbursable conditions, and tighten coding workflows. Regulators and payers are using AI to detect abnormal patterns, flag statistical outliers, and identify documentation that does not align with expected clinical behavior. 

Both sides are operating faster than traditional human oversight can follow, according to senior healthcare analyst Frank Cohen, the special guest during the next live edition of the long-running Internet broadcast Monitor Monday, coming your way Monday, May 11 at 10 a.m. EST.

Join Cohen as he walks you and your team through a labyrinth of AI obstacles so you can avoid fines, takebacks, and penalties.

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

·      Legislative Update: Folana Houston, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Documenting and coding sepsis has challenged virtually everyone in healthcare ever since Sepsis-3 redefined the condition in 2016 as a “life-threatening organ dysfunction due to a dysregulated host response to infection.”

Meanwhile, ICD-10-CM still maintains the older Sepsis-2 language of sepsis (SIRS/Systemic Inflammatory Response Syndrome due to infection, without organ dysfunction) and severe sepsis (sepsis that does result in organ dysfunction).

During the next live edition of Monitor Monday, Dr. James S. Kennedy will report on efforts currently underway to address the recent Centers for Disease Control and Protection (CDC) proposal to align ICD-10-CM to Sepsis-3/Phoenix terminology, and to introduce new codes for “impending sepsis,” also known as pre-sepsis: a morbid continuum between a localized infection with and without Sepsis-3/Phoenix-defined sepsis .

Dr. Kennedy is expected to solicit assistance from Monitor Mondays listeners toward a reasonable solution.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

The recent U.S. Supreme Court decision in Chiles v. Salazar doesn’t really close the case – but it also doesn’t really leave it open. 

The 8-1 decision, in which the nation’s highest court ruled that a Colorado ban on so-called “conversion therapy” for juveniles was unconstitutional, is subtle, complex, and unnerving; the American Psychological Association issued a statement noting that it was “deeply concerned” over it. 

The case relates to conversion therapy as talk therapy, specifically related to gender identity and First Amendment rights. But the decision only remands the matter for further review by the Tenth Circuit, thus leaving the issue essentially undecided. 

Is this just more judicial “Calvinball” – the game highlighted in the classic comic strip Calvin and Hobbes, in which the rules are made up on the fly – or is the Court simply assuring another bite at this apple? Our own Physician and attorney Dr. John K. Hall will explore these questions and look for answers during the next edition of Monitor Mondays.

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

·      Legislative Update: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Artificial intelligence (AI) is clearly here to stay – it’s now an integral part of healthcare. From coding and clinical validation to payer denials and appeals, AI is often a form of power upon which decisions are made by providers, payers, and auditors.

You and your team should be aware of the several so-called healthcare “sherpas” available to interpret vast amounts of AI-generated data, among them Grok 4: an AI-powered chatbot solution developed by Elon Musk’s xAi, which is integrated with the X (formerly Twitter) social network.

As we have before, our producers invited RACmonitor Investigative Reporter Edward M. Roche to investigate AI and its sherpas, including Grok 4, during the next edition of the long-running Monitor Mondays Internet broadcast, this coming Monday, April 20, at 10 a.m. EST.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

When the U.S. Supreme Court overturned Chevron deference, it promised to restore judicial independence and limit agency overreach. 

But in Medicare administrative proceedings, that promise remains unfulfilled. 

Tune in to the next upcoming live edition of Monitor Mondays, when senior healthcare analyst Frank Cohen will report on his surprise when an Administrative Law Judge issued a categorical ruling: Loper Bright simply does not apply to the proceedings of the Office of Medicare Hearings and Appeals (OMHA).

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Dr. Jennifer Weinberg will be making her Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

·      Legislative Update: Adam Brenman will report on current healthcare legislation.

National Doctor’s Day will bring a double whammy this coming Monday when the venerable Monitor Monday continues its recognition of the occasion with a pair of featured speakers: Drs. Drew Updike and Christopher Boyle.

The day of recognition took place on March 30, the date when Eudora Brown would place flowers on the graves of late physicians, starting in 1933. Historians are quick to note that the date also commemorates the first use of anesthesia for surgery.

Fast forward to Monday, April 6, 2026: that’s when Drs. Updike and Boyle will not only be recognized for their service by Monitor Mondays, but featured as speakers.

Broadcast segments will also include these instantly recognizable features:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.

• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

• Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Artificial intelligence (AI) is becoming part of how clinical documentation is reviewed across healthcare, from coding and clinical validation to payer denials and appeals. 

In many cases, AI is influencing decisions behind the scenes, even when it is not clearly visible.

During the next live edition of the long-running Monitor Monday, the Internet broadcast produced by RACmonitor, Sharon Easterling will explain in simple terms how AI reads the clinical record. 

Unlike clinicians, AI does not understand the full story of the patient. Instead, it looks for patterns such as words, phrases, and signals, and uses those patterns to reach a conclusion.

Because of this, the same record can lead to different outcomes. 

Easterling, RACmonitor and Monitor Monday technology consultant, returns to the broadcast and will use a straightforward way to evaluate decisions so that conclusions remain supported, clear, and defensible, even as AI becomes more involved in the process.

Broadcast segments will also include these instantly recognizable features:

·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

·      Risky Business: Healthcare attorney Amanda Mills will join the broadcast with his trademark segment.

·      Legislative Update: Matthew Albright, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

Aetna is just the latest in a long list of healthcare entities to settle False Claims Act (FCA) allegations with a massive settlement.

The insurer, one of the nation’s largest, recently agreed to pay $117.7 million to resolve a case involving purportedly inaccurate and untruthful diagnosis codes to increase payments. 

That and other recent U.S. Department of Justice (DOJ) actions will take center stage during the next edition of Monitor Mondays, when featured speakers will weigh in on striking recent trends related to such developments. Settlements and judgments under the FCA totaled $6.8 billion in the most recent full fiscal yar, an all-time record, with 84 percent of the recoveries related to matters involving the healthcare industry. 

Broadcast segments will also include these instantly recognizable features:

•Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. 

•The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. 

•Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

•Legislative Update: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.