2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert. And RACmonitor and Monitor Mondays will help you stay in front of the issues that will alter the delivery of healthcare now and for the next decade.

Monitor Monday host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2019 during the next edition of the weekly Internet broadcast:

Duane Abbey, PhD; Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Frank Cohen, MPA; William Dombi, Esq.; Knicole Emanuel, Esq.; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; Angela Phillips, PT; Lauren Riplinger, JD; Edward M. Roche, PhD, JD; and Andrew Wachler, Esq.

All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare & Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3.

Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of care management at Trinity Health, will share how her system approaches the dilemma of sepsis.

The broadcast rundown also will include:

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.
  
  
• The Audit Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, returns to report on a new audit by Brown University that reveals the targeting by Medicare Advantage auditors of certain skilled nursing facilities (SNFs).
  
  
• Monday Focus: Rural Health Report: Data from the Centers for Disease Control and Prevention (CDC) reveal another decline in life expectancy. Suicide and drug overdoses continue to be major factors, and suicide rates in rural counties are reported to be nearly double that of urban counties for 2017. Reporting on the state of healthcare in rural America is Leslie Marsh, chief executive officer at Lexington Regional Health Center in Lexington, Neb.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility
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• Hirsch’s Heroes: Dr. Hirsch will also profile his 2018 “Hirsch’s Heroes” during his popular annual holiday segment.

During this edition of Monitor Mondays, nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States declined to intervene in the case, and the allegations are likely to be dropped on Jan. 14, 2019.

The broadcast rundown also will include:

• Monday Focus: Lawmakers in Michigan have approved permanent medical marijuana licensing rules, including a provision to allow dispensaries to deliver the drug to cardholders' homes. RACmonitor investigative reporter and New York attorney Edward Roche will report on the adoption of cannabis therapy in Medicare.
  
  
• The Audit Report: Becky Charlton, RN, denials/appeals coordinator at Blessing Hospital in Quincy, Ill., reports on her hospital’s plans to appeal a denied claim for an inpatient stay by KEPRO,a Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). The episode generated national attention when it was reported that KEPRO revealed the existence of a secret CMS memo.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• 100 Percent Error Rates, Every time: Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on why he’s suspicious when auditors that review claims report 100 percent error rates, all the time.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem?

Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the American College of Physician Advisors. Dr. Baker has been working with the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in writing statements noting that these plans have to follow original Medicare regulations for non-contracted facilities. 

The broadcast rundown also will include:

• Medicare Advantage Report: A central concern about the capitated payment model used by Medicare Advantage Organizations (MAOs) is the financial incentive for them to inappropriately deny access to services and reimbursements for services rendered in order to increase their profits, according to Knicole Emanuel, partner at the Potomac Law Group, who reports on this developing story.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron answers listeners’ questions from previous broadcasts on subjects that could be potentially troublesome.
  
  
• “Hello, Are You There?” Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on problems now being created because a Quality Integrity Contractor (QIC) failed to respond to his appeal issues.
  
  
• When Minutes Count: Phones lit up and social media seemed to explode last week when CMS announced it might not allow minutes to count when therapy services are provided by students. The exclusive story was reported on RACmonitor by nationally renowned inpatient rehabilitation facility (IRF) expert Angela Phillips, the president and CEO of Image and Associates. Phillips reports on the details behind the news that is rocking IRF providers’ worlds.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates.

In other news, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Medicare Home Health final rule. Reporting on this major story will be William Dombi, president of the National Association for Home Care and Hospice.

The broadcast rundown also will include:

• Death by Cyber, Part III: RACmonitor investigative reporter and New York attorney Edward Roche will report on how healthcare IT adds to the cost of healthcare, but without offering benefits.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

Long awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to the regulations governing evaluation and management (E&M) services.

For an in-depth analysis of both the MPFS and the OPPS newly released final rules, Monitor Monday has brought together a pair of industry experts for this edition of the broadcast: Duane Abbey, president of Abbey and Abbey Consultants, and Sean M. Weiss, partner and vice president of compliance for DoctorsManagement.

The broadcast rundown also will include:

• OIG Report: In a recent study, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) reported that Medicare Advantage Organizations (MAOs) overturned 75 percent of their own prior authorization and claim denials from 2014 to 2016. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, provides details on this latest developments.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• TPE: Targeted probe-and-educate (TPE) audits are taking place in a variety of settings, from physical therapy providers to skilled nursing facilities (SNFs), including acute-care facilities. Reporting on TPE audits is Cindy Griffith, director of compliance and audits for ATI Physical Therapy.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

The Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November. The proposed changes are expected to impact compliance and reimbursement. Reporting this developing story during this edition of Monitor Mondays is author, educator, and consultant Duane Abbey, who will discuss how the proposed changes are likely to impact Medicare providers.

The broadcast rundown also will include:

• False Claims Act: Famed whistleblower attorney Mary A. Inman, a partner at Constantine Cannon’s London office, reports that DaVita Medical Group has agreed to pay $270 million to CMS to settle False Claim Act allegations over questionable billing practices that led Medicare Advantage plans to receive inflated Medicare Part C risk adjustment payments.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• Legislative Update: In California, there’s a bill on the November ballot (SB 1152) that would amend an existing law by establishing a uniform discharge planning process that takes into account the unique needs of homeless patients. Reporting on this proposition is Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital, east of Los Angeles.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

The Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program. Reporting this developing story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, who will discuss how the proposed changes are likely to impact Medicare providers.
The broadcast rundown also will include:

• TPE: Targeted Probe and Educate Audits continue to generate confusion and concern. Returning to report on this developing story is healthcare attorney Andrew Wachler who has a follow-up to his reporting last Monday on Monitor Monday.
  
  
• Death by Cyber, Part II: RACmonitor investigative reporter and New York attorney Edward Roche reports on how healthcare IT enables pharmacy benefit managers to keep drug prices high.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to a Recovery Audit Contractor (RAC), suspension of Medicare payments, or even revocation of Medicare billing privileges.

Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. Wachler offers some practical tips and strategic approaches for responding to TPE audits to reduce claim denials.

The broadcast rundown also will include:

• Developing Story: PIM Change: CMS is proposing major changes to the Program Integrity Manual (PIM) – changes that will take effect Jan. 1, 2019. Senior healthcare analyst Frank Cohen, director of analytics and business intelligence for DoctorsManagement, reports on the changes involving sampling and extrapolation.
  
  
• Death by Cyber: RACmonitor investigative reporter and New York attorney Edward Roche suffered a life-threatening medical emergency while in Barcelona, Spain. Roche reports on the one mainstay of America’s hospitals that was missing while he was hospitalized and ultimately experienced a complete recovery.
  
  
• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest with TPE audits.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

Register now for this important news broadcast coming up at 10 a.m. EST on Monday, Oct. 15.

UnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present.  

If reviewers find no SOFA score in the medical record, that could spell trouble – audit trouble. Reporting on this topic during this edition of Monitor Mondays is Edward Hu, MD, executive director of Inpatient Physician Advisor Services for the University of North Carolina Health Care System and president of the American College of Physician Advisors.

The broadcast rundown also will include:

• The RAC Report: Healthcare attorney Knicole Emanuel reports on a flurry of new cases in which judges are ordering the government to refrain from recouping alleged overpayments until a hearing has been held. Immediate recoupments, currently allowable by law, fundamentally violate our country’s concept of due process.

• Medicare Advantage Report: A recent investigation by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that Medicare Advantage plans overturned 75 percent of their denials. Timothy Powell, Monitor Monday national correspondent, reports on this developing story.

• Rural Health Report: There has been a spike in the closure of rural hospitals, according to the Government Accountability Office (GAO). In a recent report, the GAO says that a total of 64 rural hospitals closed between 2013 and 2017. In the face of that bad news, Leslie Marsh, the chief executive officer for Lexington Regional Health Center in Lexington, Neb., reports on the positive economic impact her facility is having on the community.

• Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.

• Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

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