Monitor Mondays

A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program. 

U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association v. Alex M. Azar, HHS Secretary, ordering HHS back to the drawing board and warning it to act with haste to make a correction. 

Reporting our lead story during this edition of Monitor Mondays is RACmonitor national correspondent Timothy Powell. 

Other segments to appear on the broadcast include:

• Court Report: Two more pharmaceutical companies have agreed to pay $125 million to resolve allegations that they paid kickbacks through co-pay assistance foundations. Famed whistleblower attorney Mary Inman has an update on this story, which she first reported on April 15. Inman is a partner in the London office of Constantine Cannon. 
  
  
• Monday Focus: What are the issues when trying to project the results of an audit to a larger population of providers? Senior healthcare analyst Frank Cohen with DoctorsManagement reports on the myth surrounding pass/fail rates for providers. 
   
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and 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 problematic issues facing providers. 
  • Link for Davids segment:  The new guidance about co-location of space in hospital-based space, New DOJ guidance about Cooperation in False Claims Act Cases
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. 
  • Links for Dr. Hirsch's segment:  PREOPERATIVE MEDICAL TESTING BEFORE CATARACT SURGERY,  Reduce Low-Value Preoperative Care 

Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and frustration.

Reporting our lead story during this edition of Monitor Mondays is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States in partnership with hospitals and health systems. Dr. Seward is a recent addition to the RACmonitor editorial board.

Other segments to appear on the broadcast include: 

• Program Integrity Issues: Healthcare attorney Andrew Wachler, a managing partner at Wachler & Associates, reports on Center for Program Integrity (CPI) priorities for 2018 and 2019, including remarks on the various contractors and their methodologies.
  
  
• Court Report:  US WorldMeds (USWM) LLC has agreed to pay $17.5 million to resolve allegations that it violated the False Claims Act by paying kickbacks to patients and physicians to improperly induce prescriptions of its drugs, Apokyn®, and Myobloc®. USWM is a pharmaceutical manufacturer headquartered in Louisville, KY. Famed whistleblower attorney Mary Inman reports this developing story. Inman is a partner in the London office of Constantine Cannon
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and 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 problematic issues facing providers. 
  • Links from Davids Segment  
    • Center for Clinical Standards and Quality/Quality, Safety & Oversight Group
    • 4-4.000 - COMMERCIAL LITIGATION
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. 

The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid.

More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. Could the CMS initiative suggest cost-cutting, administrative burden reductions, or true innovation? RACmonitor national correspondent J. Paul Spencer, a senior health consultant for DoctorsManagement, reports our lead story during this edition of the long-running Monitor Mondays live broadcast.

Other segments to appear on the broadcast include:

• Court Report: Famed whistleblower attorney Mary Inman reports on the guilty verdict handed down Thursday by a federal grand jury in Boston that found Insys Therapeutics founder John Kapoor and four other executives guilty of criminal racketeering in bribing physicians to prescribe powerful opioids to patients who didn’t need them. Inman is a partner in the London office of Constantine Cannon.
  
  
• 2020 IPPS Proposed Rule: Social determinants of health (SdoH) are back in the news, since CMS is proposing to make homelessness a CC (complication and comorbidity) for the purposes of Inpatient Prospective Payment System (IPPS) coding. Does the CMS action signal that SDoH are a growing concern in the nation’s healthcare landscape? Continuing our reporting on this hot topic is nationally recognized SDoH authority and author Ellen Fink-Samnick.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will report on all the latest hot topics and 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 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. 

News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing.

Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albright will also report on drug rebate discussions and how those discussions are being impacted by broader reform proposals such as Patient Protection and Affordable Care Act (PPACA) stabilization, outright repeal, and Medicare-for-all.

Other segments to appear on the broadcast include:

• Monday Focus: Targeted Probe-and-Educate (TPE) audits are the Monday Focus, healthcare attorney Knicole Emanuel returns to the broadcast to report on what is believed to draconian efforts by TPE auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.
  
  
• IPPS Proposed Rule: Reporting on the release of the CMS proposed 2020 Inpatient Prospective Payment System (IPPS) rule for acute-care hospitals will be ICD10monitor contributing editor Laurie Johnson, a senior healthcare consultant with Revenue Cycle Solutions. See Laurie's Handout here.
  FY 2020 Proposed Rule Tables
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics, including confusion surrounding the former functional G codes once used for Functional Limitation Reporting (FLR). Beckley 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.

New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA.

Other segments to appear on the broadcast include:

• Monday Focus: Healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will provide context and perspective to the ECAPE system at the OMHA.
  
  
• IFF Report: One of the nation’s foremost authorities on inpatient rehabilitation (IRF) Angela Phillips will report on the proposed 2020 Inpatient Prospective Payment System (IPPS) for IRF that CMS posted on Wednesday. 
  
  
• The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on compliance issues associated with robotic surgery.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and 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, will be making his Monday Rounds with another installment of his popular segment. 

The Centers for Medicare & Medicaid Services (CMS) recently announced that 800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row (the HAC Reduction Program has only been in existence for five years).  

The Code of Federal Regulations does not allow a hospital to appeal the determination of poor results in this program, whereas if you are penalized by a Recovery Audit Contractor (RAC) or a Zone Program Integrity Contractor (ZPIC), you do have the right to appeal. With courts now finding that Medicare reimbursements are a property right, is 42 CFR 412.172 unconstitutional because it disallows an appeals process for a decrease in Medicare payments? 

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

Other segments to appear on the broadcast include:

• Monday Focus: The American Hospital Association (AHA) and the National Quality Forum have released a guide to help hospitals and health systems deliver tele-behavioral health services to improve patient outcomes and enhance access to behavioral healthcare. An estimated 44 million Americans have a behavioral health disorder. Reporting 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 in partnership with hospitals and health systems. 
  
  
• Big Pharma Lawsuits: Three pharmaceutical companies – Jazz Pharmaceuticals plc, Lundbeck LLC, and Alexion Pharmaceuticals, Inc. – have agreed to pay a total of $122.6 million to resolve allegations that they violated the False Claims Act by paying kickbacks to Medicare and Civilian Health and Medical Program (ChampVA) patients through purportedly independent charitable foundations. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story. 
  
  
• The IRF Countdown Continues: The Inpatient Rehabilitation Facility (IRF) countdown to Oct. 1, 2019 will end with the change to use quality indicators for case-mix group (CMG) for payment calculation. Reporting this story is one of the nation’s foremost IRF authorities, Angela Phillips, president of Images & Associates and longtime RACmonitor editorial board member and Monitor Mondays panelist. 
  
  
• 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 use and apparent abuse of observation and outpatient status are expected to have its day in court – again. 

That’s because a federal judge has denied the government’s bid to put a stop to a landmark class-action lawsuit centering on patient status, paving the way for a trial expected to begin later this year. As reported by RACmonitor, in the court case Alexander v. Azar, the plaintiffs allege they were forced to pay up to $30,000 apiece for skilled nursing facility (SNF) care after being designated outpatients in observation status rather than inpatients, according to a press release on the matter by the Center for Medicare Advocacy (CMA). 

Reporting on this important story during this edition of Monitor Mondays will be Judith A. Stein, the founder of CMA. She has extensive experience with Medicare advocacy projects, representing Medicare beneficiaries, producing educational materials, teaching, and consulting. She has been lead or co-counsel in numerous federal class-action and individual cases challenging improper Medicare policies and denials.

Other segments to appear on the broadcast include:

• Monday Focus: The Medicare Home Health Review Choice Demonstration is expected to start in Illinois on June 1. The president and CEO for the National Association of Home Care and Hospice, William Dombi, reports on this latest news, which was announced on Wednesday. 
  
  
• Social Determinants of Health: A nationally recognized authority on the social determinants of health (SdoH), Ellen Fink-Samnick, returns to Monitor Mondays to report on the American Medical Association (AMA) and UnitedHealthcare agreeing to work together to support creating 23 new ICD-10 codes to report SDoH needs. 
  
  
• 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.

In the final installment of a two-part series on prescription drug prices, during this edition of Monitor Mondays we will report on the latest initiative on a new “war on drugs” – the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered under the 340B federal drug program. Reporting on this development will be Maureen Testoni, Esq., president and CEO for 340B Health. 

Other segments to appear on the broadcast include:

• Monday Focus: J. Paul Spencer, senior healthcare consultant for DoctorsManagement and a RACmonitor national correspondent, reports on the latest update to the American Medical Association’s (AMA’s) 2021 evaluation and management (E&M) changes. https://www.racmonitor.com/an-overview-of-ama-s-e-m-revisions-for-2021/
  
  
• Whistleblower Report: MedStar Health of Maryland has agreed to pay the government 35-million dollars to resolve allegations of under the False Claims Act that it paid kickbacks to a cardiology group. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story. 
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and conducts the Monitor Mondays Listener Survey.  Click to view SNF Prospective Payment PDF
  
  
• 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: Howard A. Stein, DO, associate director of medical affairs for Centrastate Medical Center, makes his Monday rounds in the absence of Ronald Hirsch, MD.
  
  
  

In the first portion of a two-part series on prescription drug prices, during this edition of Monitor Mondays we report on the Centers for Medicare & Medicaid Services (CMS) Drug Spending Dashboards with data for 2017.

First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousands of more drugs across Medicare Parts B and D and Medicaid. Reporting Part I of the series will be Timothy Powell, a regulatory expert and a RACmonitor national correspondent. 

During Part II, scheduled for April 1, Maureen Testoni, president and CEO for 340B Health, will report on the state of the union of the drug discount program.

Other segments to appear on the broadcast include:

• The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on the use of artificial intelligence (AI) to detect fraud in social health insurance programs.
  
  
• CHS Whistleblower Lawsuit: Two former Community Health Systems (CHS) employees have alleged that CHS submitted hundreds of millions of dollars in false claims to the U.S. Department of Health and Human Services (HHS) for federal incentive payments under the CMS interoperability program for electronic health records. The whistleblowers allege that CHS received more than $450 million in incentive payments between 2012 and 2015. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story.
  
  
• Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will 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 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. 

Could the Empire State be among the first to introduce a single-payer healthcare system?

The latest news coming from Albany would seem to indicate that; now that both state legislative branches are under control of the Democrats, such an option is likely viable. Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no access to healthcare.

Reporting our lead story during this episode of Monitor Mondays will be Dennis Jones, a New Yorker and the administrator of patient financial services at Montefiore Nyack Hospital in Nyack, N.Y.

Other segments to appear on the broadcast include:

• Monday Focus: Revised E&M Codes: As expected, the American Medical Association’s (AMA’s) CPT® editorial board last month approved major changes to documentation and code selection guidelines for evaluation and management (E&M) codes. The changes were announced last week and are expected to become effective in 2021. Reporting this developing story is Shannon DeConda, founder and president of the National Alliance of Medical Coding Specialists—NAMAS
  
  
• Whistleblower Report: Walgreens is facing a whistleblower’s False Claims Act challenge. The lawsuit alleges that pharmacies that the giant retail purchased in 2012 overcharged Medicaid for generic drugs by steeply discounting them to cash-paying customers. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, has the latest news on this major story.
  
  
• 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.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
  • Extrapolation Changes: Part II: The Centers for Medicare & Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, continues  reporting on the changes and what they mean to providers.