Monitor Mondays

Pick up any healthcare news feed or relevant state or federal initiative, and no doubt you will see the "surprise billing" issue headlining. The issue of a patient not knowing that a provider is not in their network is important, but there is another major cause of surprise bills: insurance plans denying legitimate claims for emergency care as "non-emergent." 

Prudent acts among patients are ignored, common sense is discarded, and ethical conduct is cast aside in order to insist that patients pay astronomical bills for services that truly constitute emergency care. 

These battles can take years. One such case will be discussed during this edition of Monitor Mondays; reporting our lead story will be Holly Louie, herself once an emergency department nurse.

Other segments to appear on the broadcast include:

• Monday Focus: Bogus Charity Write-offs: The Patient Protection and Affordable Care Act (PPACA) created a new provision in Section 501 of the Internal Revenue Code that applies to facilities licensed as hospitals under state law, with new requirements for uncompensated care. The law also imposed new reporting requirements on hospitals. Running afoul of this issue could be a significant compliance violation, as you’ll learn when Timothy Powell reports on what many experts believe could be a major compliance bust.
  
  
• United Behavioral Health Lawsuit: On Tuesday, a federal court in California found that United Behavioral Health (UBH) denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral healthcare. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, will have the latest news on this major story.
  
  
• Extrapolation Changes: 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, reports on the changes and what they mean to providers
  
  
• 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 preponderance of ambiguously worded regulations from federal agencies – think the Centers for Medicare & Medicaid Services (CMS) – will be at the center of a major legal challenge coming March 26 to the nation’s highest court, and you’ll hear the details here during this edition of Monitor Mondays.

That’s when Jennifer Gustafson will report our lead story, focusing on the U.S. Supreme Court (SCOTUS) taking up the case of Kisor vs. Wilkie (U.S. Marine James Kisor vs. the U.S. Department of Veterans Affairs).

The dispute is over denied Veterans Affairs (VA) benefits. In 1997, SCOTUS ruled that generally, federal courts are required to accept an administrative agency’s interpretation of its own ambiguous relations; this rule today is known as Auer deference.

Gustafson is a founding shareholder with The Health Law Partners, representing hospitals, health systems, hospices, home health agencies, physicians, and other healthcare providers and suppliers in an array of legal matters.

Other segments on the broadcast include:

• Monday Focus: LTACH vs. Managed Care: Limiting access of Medicare patients to long-term acute care (LTAC) facilities by health insurance companies; reported on by Marvin Mitchell, the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles.
  
  
• Prime Healthcare: Prime Healthcare Services will pay $65 million to settle a federal whistleblower lawsuit that accused the California hospital chain of Medicare fraud. Famed whistleblower attorney Mary Inman, 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.
  
  
• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, maks his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also be following up on his segment last Monday on how to bill for inpatient services when there is no admission order.

Reaction to the reporting here on forensic audits continues to reverberate. During last week's Monitor Mondays broadcast, Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc., reported on her experience and efforts to appeal what she describes as "spurious" denials. As reported last Monday, these denials are for commonly billed services and items such as IV solutions, supplies, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc.

Michael Lewis, president of Financial Review Services of Houston, Tex. continues our reporting on this topic during this episode.

The episode rundown also includes:

• Monday Focus: Analytics: Apropos of the lead story on forensic audits, senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, returns to the broadcast to report on the use of analytics to determine outliers.
  
  
• The Roche Report: RACmonitor investigative reporter and New York attorney Edward Roche returns to the broadcast with another one of his intriguing reports on an under-reported healthcare issue.
  
  
• 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. Dr. Hirsch also reports on how to bill for inpatient services when there is no admission order.

Monitor with us™

Many hospitals are seeing increasing numbers of significant payment reductions that are the result of so-called “forensic” or other reviews conducted by third-party auditors. These are done on outlier claims, particularly for Medicaid HMO claims, as well as commercial and even Medicare Advantage claims.

The denials are for commonly billed services and items such as supplies, IV solutions, point-of-care (POC) labs, venipuncture, respiratory therapy services, etc. The rationale given for the denials is that the charges are “unbundled” and should be included in a room rate or a procedure charge, or labeled “routine,” and thus not separately billable or payable.

Appeals are reported to be very time-consuming, with no guarantees of success. Reporting our lead story during this edition of Monitor Mondays will be Amanda Gilliland, a revenue integrity nurse auditor at UW Health in Madison, Wisc. Gilliland reports on her experience and efforts to appeal what she describes as “spurious” denials. 

The broadcast rundown also will include:

• Monday Focus: Readmissions: The Hospital Readmission Reduction Program (HRRP) penalizes hospitals for excessive readmissions that are often the result of a poor discharge process and medical decision-making. Reporting on readmissions will be Dennis Jones, administrator of patient financial services for Montefiore Nyack Hospital in New York.
  
  
• Providence Lawsuit: Nationally recognized whistleblower attorney Mary A. Inman, 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.
  
  
• Monday Focus: TPE Audits. Two different Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs), two different audits, both for the same issue: knee orthotics. Reporting on this topic will be Leann Wilhelm, a compliance officer for Kinex, a multi-state DME company located in Milwaukee, Wisc.
  
  
• 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.

“It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place," President Donald Trump told members of Congress during his State of the Union address on Wednesday. "This is wrong, unfair, and together we will stop it. We will stop it fast," the President warned. During his address, the President also pledged to end the HIV epidemic in the nation.

Both issues will be discussed during this edition of Monitor Mondays, when Maureen Testoni, president and CEO for 340B Health, returns to the broadcast. Testoni is considered to be one of the nation’s leading experts on the 340B drug pricing program and was recently was recognized as one of the “100 Most Influential People in Healthcare” by Modern Healthcare.

The broadcast rundown also will include:

• Medicare Advantage: Are managed care beneficiaries being deprived of an important benefit? Enrolling in MA plans, beneficiaries expect to receive the same benefits as in traditional Medicare. But as providers move toward DRG payments, MA plans decline authorization for long-term acute care (LTAC) for patients with prolonged respiratory requirements and those with prolonged needs. MA plans feel that these patients should remain in the hospital under the original DRG payment. Reporting on this developing story is Howard Stein, MD, associate director of medical affairs and physician advisor in care management at CentraState Medical Center in Freehold, N.J.
  
  
• Anthem Lawsuit: Nationally renowned whistleblower attorney Mary Inman reports on the recent class action lawsuit filed against Anthem Health.
  
  
• Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on a scientific breakthrough in DNA sequencing.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.
  
  
• 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: Juliet Ugarte Hopkins, MD, Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin makes her Monday rounds while substituting for Dr. Ronald Hirsch.

Are you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied? 

Are you being told you cannot have a peer-to-peer session because your request was considered late? 

Are you hearing that you must have everything — “pre-denial” or “pre-auth” — done within 72 hours of notification, only they typically wait until they only have three hours left? 

During this edition of Monitor Mondays, listen and learn what Val Kraus and his team at one major Midwest health system are doing to reduce the impact of these scenarios.

The broadcast rundown also will include:

• Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on what he says is the death of statistical extrapolation of Medicare audits by way of qui tam demands.
  
  
• Opioid Crisis: The Purdue Lawsuit: Nationally renowned whistleblower attorney Mary Inman, featured in The New Yorker, returns to the broadcast to report on the major opioid lawsuit involving Purdue Pharma. The lawsuit is part of a national effort to force pharmaceutical companies to pay, in part, for the damage inflicted as a result of opioid healthcare crisis.
  
  
• Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on Medicare Advantage and other problematic issues facing providers.
  
  
• 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.

Register now for this important news broadcast coming up at 10 a.m. EST on the first Monday of the month, Feb. 4, 2019. 

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an updated memo on the subject on Thursday.

The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story during the next edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare.

The broadcast rundown also will include:

• Monday Focus Report: Blockchain: Distributed ledger systems (DLS), also known as blockchain, will be the Monday Focus when RACmonitor investigative reporter and New York attorney Edward Roche will report on new healthcare technologies we can expect to see in 2019.
  
  
• War on Drugs: The U.S. Department of Justice announced this week that Walgreens Boots Alliance agreed to pay $269.2 million to settle two healthcare fraud lawsuits alleging that Walgreens overbilled the government. In a related matter, United HealthCare Services filed a federal lawsuit last week against more than 40 drug companies, alleging they violated federal and state antitrust laws. Whistleblower attorney Mary Inman will report on both lawsuits.
  
  
• Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment “Risky Business,” in which he reports on problematic issues facing providers.
  
  
• 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.

On Tuesday, the Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2.

Dennis Jones, the administrator of patient financial services for Montefiore Nyack hospital, was there Tuesday when HANY made the announcement during its regularly scheduled managed care advisory group meeting. Jones, who was among the earliest correspondents to join Monitor Mondays in 2010, will return to the broadcast this coming Monday and report on this newly developing story. Also reporting on Sepsis-3 will be Denise Wilson, vice president of Intersect Healthcare + AppealMasters.

The broadcast rundown also will include:

• False Claims Act: Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report on Intermountain taking its challenge of False Claims Act (FCA) to the Supreme Court.
  
  
• The Audit Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, will report on the latest activities by auditors, including the Recovery Audit Contractors (RACs).
  
  
• 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.

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.