Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable tragedy.  

RACmonitor Editorial Board member, investigative reporter, and New York attorney Edward Roche returns Monitor Mondays with this exclusive story about a durable medical equipment (DME) provider facing auditors who, in his words, had gone rogue.

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

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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.
  
  
• The Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports on a controversial decision made last week, when U.S. District Judge David Ezra, sitting in Texas, dismissed a whistleblower’s complaint alleging that an executive with Baylor University Medical Center created an upcoding scheme to overcharge Medicare.
  
  
• 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. See Ellens Survey Results
  
  
• 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. 

Obtaining an injunction in federal court to lift a suspension of access to Medicare or Medicaid funds is rare, according to healthcare attorney Knicole Emanuel. 

As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons that might explain such a mystery during this edition of Monitor Mondays.

Other segments to appear includes:

• IRF Report: Angela Phillips, considered to be one of the nation’s foremost authorities on inpatient rehabilitation facilities (IRFs), reports on the final rule for the IRF prospective payment system for the 2020 fiscal year.
  
  
• The Court Report: Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, reports on a $57 million fraud scheme that involved laundering money through a hospital.
  
  
• 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 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.

The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the institution – and obviously, the referral from the community will have a lower payment. 

Judith A. Stein, JD, executive director of the Center for Medicare Advocacy, reports on this story, along with William Dombi, Esq. president of the National Association of Home Care and Hospice, during this edition of Monitor Mondays.

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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 will also conduct the Monitor Mondays Listener Survey.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, and will 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. 

Reports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare.

Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.”

This is but one example of Medicare Advantage (MA) plans misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care they provide to their members. Reporting on this development during this edition of Monitor Mondays is Steve Phillipson, Director of Hospital Medicine at Aspirus Wausau Hospital, in Wausau, Wis.

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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.
  
  
• Monday Focus: Marvin D. Mitchell, Director of Case Management and Social Services at San Gorgonio Memorial Hospital in Banning, Calif., east of Los Angeles, reports on the potentially adverse issues associated with “copy-and-paste” functionality in electronic medical records (EMRs).
  
  
• 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. 
  
  
• 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.

There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits. 

Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documentation can easily lead to higher reimbursement – and the likelihood of audits leading to claim denials. 

Reporting on this development during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group.

Other segments to appear during broadcast include:

• Court Report: The Reckitt Benckiser Group has agreed to pay $1.4 billion to resolve its potential criminal and civil liability related to a federal investigation of the marketing of the opioid addiction treatment drug Suboxone. Whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports on how an addiction specialist filed a False Claims Act (FCA) motion leading to the largest settlement in U.S. history related to the opioid crisis.
  
  
• Monday Focus: Senior healthcare analyst Frank Cohen returns to Monitor Mondays with a unique perspective on artificial intelligence (AI). Cohen reports on how the more accurate term for the ubiquitous AI should be “augmented intelligence,” as it relates to non-clinical areas of healthcare.
  
  
• SDoH Report: Ellen Fink-Samnick, 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 also conducts the Monitor Mondays Listener Survey.
  
  
• 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. 

An older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records.

In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary fines and penalties. What could have possibly triggered this investigation?

Reporting this developing story during this edition of Monitor Mondays is Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS). DeConda, who personally talked to the rural West Virginia physician, will report on the latest development in the case of a healthcare professional who plans to tell a jury of his peers that he didn’t swindle Medicare for money at their expense.

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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.
  
  
• Monday Focus: John K. Hall, MD continues his reporting on the now-infamous blog post of May 2, by Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator. Hall reports that he expects that providers can expect more Recovery Audit Contractor (RAC) audits as a result of her blog. Hall is the founder of the Aegis Firm.
  
  
• SDoH Report: Ellen Fink-Samnick, a nationally recognized expert on 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.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on Split Shared Evaluation and Management EM Services.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on the volume of claims?  Reporting this developing story during the next edition of Monitor Monday will be John K. Hall, MD, founder of The Aegis Firm. 

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel will return to the broadcast to report 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 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 Listener Survey.
  
  
• Monday Focus: Several different trends are simultaneously affecting physician payment even delimiting consideration to the Medicare program.  Reporting on these trends and their impact on physician reimbursement and compliance requirements will the author, educator and consultant Duane Abbey, president of Abbey & Abbey Consultants, Inc.
  
  
• Risky Business: Healthcare attorney David Glaser will return 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, will be making his Monday Rounds with another installment of his popular segment. 

Under siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey. 

Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey results and the import of its findings during this edition of Monitor Mondays Maureen Testoni, president and CEO for 340B Health. 

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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 social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention. 
  
  
• Monday Focus: A recent study by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has revealed a concerning series of findings related to the under-reporting of instances of potential abuse and neglect of elderly Medicare patients. Reporting on this developing story is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States. 
  
  
• Case Managers at Risk: Complaints associated with discharge planning can involve allegations that a patient was discharged before they were medically stable enough to leave the hospital, or that services or supplies required in the outpatient setting were not provided. These and other incidents point to the legal liability of case managers. Reporting this developing story is Juliet Ugarte Hopkins, MD, physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. 
  
  
• 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. 

U.S. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health Committee, appears to be ready to shepherd his 165-page draft legislation on surprise balance billing for a vote next week. 

In their push to get legislation prohibiting such billing through before the August recess, both the House and Senate have held hearings in the past two weeks on the various approaches to the problem. Those hearings have made the industry battle lines clearer, in terms of how the various industry sectors think that out-of-network providers should be compensated by payors. 

Although no single approach appears to be significantly favored at this point, Matthew Albright, former Centers for Medicare & Medicaid Services (CMS) official reports the lead story during this edition of Monitor Mondays. 

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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 social determinants of health (SdoH), has the latest news on this trending topic that is attracting significant media attention.
  
  
• CMS/IRF Settlement:  As reported by RACmonitor, the Centers for Medicare & Medicaid Services (CMS) agreed last week to settle appeals for inpatient rehabilitation facilities (IRFs) following a two-year dispute with the industry. Reporting on this developing story will be Angela Phillips, president of Images & Associates, and one of the nation’s foremost IRF authorities.
  • Links from Ellen's segment: Commonwealth Fund, Kaiser Family Foundation 1, Kaiser Family Foundation 2,  Harvard TH Chan School of Public Health, Medicaid Work Requirements Chart
• News from OMHA: The Office of Medicare Hearings and Appeals (OMHA) has expanded its Settlement Conference Facilitation (SCF) program, and it is now open to the appellant community. Healthcare attorney Andrew Wachler, a managing partner at Wachler and Associates, reports on how these expanded eligibility requirements provide new opportunities for appellants. 
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  Links from David's segment: 
  • Supreme Court Case that says CMS must follow a more stringent process for issuing new rules than the Administrative Procedure Act requires.
  • Fraud Alert: Genetic Testing Scam
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

Most likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years. 

But how can you and your team effectively deal with them? What tools and techniques are available? 

During this edition of Monitor Mondays, John K. Hall, MD, founder of The Aegis Firm and the newest member of the RACmonitor editorial board, will make his debut appearance on the broadcast to report on how payers are denying claims and how best to avoid them. 

Other segments to appear during the live broadcast include:

• RAC Report: Healthcare attorney Knicole Emanuel returns to the broadcast to report 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. 
  
  
• False Claims Act Report: The U.S. Attorney’s Office in Chicago announced this week that a Chicago-area physical therapy center and four nursing facilities have agreed to pay $9.7 million to resolve civil allegations that they violated the False Claims Act by providing unnecessary services to increase Medicare payments. The owner of the skilled therapy service provider was excluded from the Medicare program for five years. On hand to explain the significance of this unusual case will be famed whistleblower Mary Inman, partner in the London office of Constantine Cannon. 
   
• 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, will make his Monday Rounds with another installment of his popular segment.