Healthcare providers nationwide are facing menacing interactions with auditors that, like hungry predators, are looking at submitted claims for the slightest evidence of omission or commission as the justification to pounce.

But it’s not so much the actual auditing as the long and wearisome journey of appeals – and the very real possibility of financial disaster. Although medical record auditing is not new, its frequency and alleged abuses contribute to a tell a tale of tragedy for America’s healthcare system.

That is why each and every Monday morning, Monitor Mondays has been alerting its listeners as to consequences of auditing gone awry – but also reporting on preventative measures providers can take to help their facilities avoid takebacks and fines.

This coming Monday, Monitor Mondays will continue with its reporting on auditors behaving badly.

That’s when listeners will hear of complication and comorbidity (CC) risk scores: a relative measure of the average health (or lack of health) for a Medicare beneficiary. The higher the score, the more cost to the system, and subsequently, the higher the payment for care. 

Out of this model was born clinical documentation improvement, or CDI – a push to improve documentation so that it improves the reporting of diagnoses and procedures, thereby optimizing the scores. But with this comes the opportunity for abuse. 

So, can these risk scores help predict whether a provider is under-coding, over-coding, or coding optimally? 

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 Practus, will report the latest news about auditors.
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.
• Legislative Update: Adam Brenman, federal legislative analyst for Zelis, will report on current healthcare legislation.
• The Cohen Report: Senior healthcare analyst Frank Cohen will file the second report in his two-part series on his research findings that Hierarchical Condition Category (HCC) risk scores could be used to negotiate Medicare Advantage rates.
• Livestream Chat: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning’s top stories.