Monitor Mondays

The San Diego chapter of the Association of Clinical Documentation Integrity Specialists (ACDIS) is meeting this week in San Diego, attracting a host of well-known CDI subject-matter experts, including James S. Kennedy, MD. and our very own Penny Jefferson, cohost of Talk Ten Tuesdays. Kennedy, a frequent panelist on both Monitor Monday and Talk Ten Tuesday, has agreed to be the latest special gue...

You’re invited to take a journey with us as we spend time walking in the shoes of professional case managers, during National Case Management Week. Join us during the next live edition of the venerated Monitor Monday weekly Internet broadcast. You’ll feel the sense of excitement. The energy is palatable as these care professionals work to improve patient care outcomes and reduce readmissions while...

Federal officials announced that a Fortune 500 healthcare devices and medical supplies company has agreed to pay just shy of $385 million to resolve allegations involving issues with its production of baby formula. During the next live edition of the venerable Monitor Mondays weekly broadcast, famed whistleblower attorney Mary Inman, reports on this major false claim act settlement. The long-runni...

Government agencies routinely publicize allegations and settlements. But convictions are different – and far more consequential. When a court reaches such a judgment, the warning is no longer theoretical. Understanding how and why entities or individuals are refunding money or serving prison time as result of valid evidence and the judgment of a court helps give a clearer awareness of regulatory a...

As expected, Monitor Monday continues to focus squarely on healthcare auditing and compliance. During the next live edition of the venerable Internet broadcast, Monitor Monday will examine a range of compliance and auditing concerns associated with skin lacerations. Led by esteemed physician and popular program special guest Dr. James S. Kennedy, the program will take listeners on a fascinating de...

Artificial intelligence (AI) is dramatically reshaping healthcare by accelerating data analysis, auditing, and documentation. But while it appears to reduce provider burden, AI also strengthens medical necessity support. What about compliance – and the role of human oversight? The producers of Monitor Mondays have invited senior compliance consultant Veronica Richardson with First Class Solution t...

There has been a noticeable recent surge of activity among data-mining companies or individuals who analyze publicly available government data for potential signals of fraud, rather than the insiders who have traditionally served as relators under the federal False Claims Act (FCA). As such, the venerable U.S. Department of Justice (DOJ) has a new process in place to mitigate the trend. It’s calle...

Program Update: CMS-2451-F has been published in the Federal Register. The proposed rule is effective Oct. 13, 2026. The recently posted rule prohibits federal and state Medicaid and CHIP program dollars from being spent on gender-affirming care for persons under 19 years of age. Earlier this year, CMS-3481-P —a related proposed rule— was reported by Drew Updike, MD, a senior healthcare consultant...

Much like the iconic TV commercials in which the late newscaster John Cameron Swayze would demonstrate on live television how the venerable Timex wristwatch could withstand relentless beatings and “could keep on ticking,” the venerable federal drug program, 340B, continues in its role to provide expensive drugs at discounted prices to the nation’s safety-net hospitals. Due to recent legislation in...

You wear a smartwatch as do so many other Americans. In fact, AI is transforming wearable healthcare devices from simple fitness trackers into powerful tools that collect, analyze, and share health information in real time. During the next live edition of the long-running Monitor Monday Internet broadcast, special guest Ray Ribble will take a deep dive into AI-powered wearables and explain what yo...

The Department of Justice (DOJ) recently announced “data sharing” agreements with the Centers for Medicare & Medicaid Services (CMS), the Department of Homeland Security (DHS) and the Federal Trade Commission (FTC). Many believe this latest development might be the most consequential enforcement shift in twenty years. DOJ can now run analytics directly against CMS claims data, DHS travel recor...

Maybe it’s the summer doldrums that keep otherwise rational people from taking a chance—especially when better alternatives may be available. But according to physician and attorney Dr. John K. Hall, the special guest on the next live edition of Monitor Mondays, some individuals prefer to maintain the status quo rather than pursue a potentially better approach. Case in point: Aetna’s recent discha...

Who would have thought that the otherwise fairly simple Medicare Cost Report could be a serious compliance trap? Some are calling the new Medicare report worksheet a possible precursor to the most significant reimbursement change in decades. For 2026, the Centers for Medicare & Medicaid Services (CMS) will require hospitals to report Medicare Advantage (MA)-negotiated reimbursement by Medicare...

Payer-driven clinical validation is a common reason given by payers to remove ICD-10-CM/PCS diagnosis and procedure codes affecting reimbursement or quality-based payment models (e.g., the Centers for Medicare & Medicaid Services/CMS Hospital-Acquired Conditions), even though these codes are based on the documentation of licensed providers. During the next Internet broadcast of the venerable M...

Behavioral health services continue to face heightened payer scrutiny. The result: inaccurate documentation, coding, and compliance issues. Panacea Healthcare recently hosted a webinar that focused on three high-risk areas: relative to Behavioral Health–telehealth, psychotherapy with evaluation and management (E&M) services, and the Collaborative Care Model (CoCM). Special guest George Kelly i...

There’s a method by which providers can avoid the snare of the latest claim denial strategy to garner attention. Much has been written about the Aetna policy for its “severity inpatient payment” element. Yet almost daily, providers appear to be turning to trusted sources to avoid pitfalls. And that is why the producers of RACmonitor’s Monitor Mondays have invited physician and attorney Dr. John K....

Motivated by the notion that healthcare providers are seeking compliance solutions across the revenue cycle, the producers of Monitor Mondays have invited the CEO of Panacea Healthcare Solutions to serve as the special guest during the next upcoming broadcast. Introducing Kevin Chmura. For more than 25 years, Mr. Chmura has been at the forefront of major healthcare vendors as they, in turn, have w...

Maureen Testoni, the stalwart president and CEO of the renowned 340B Health Program, will join the long-running Monitor Mondays to discuss Eli Lilly’s escalating demands for hospitals to submit in-house claims data as a condition of receiving 340B drug discounts.  Who will blink first? Register now to reserve your participation. Broadcast segments will also include these instantly recognizable fea...

At the heart of a recent lawsuit filed by a physician is whether the medical profession’s understanding and practice of racial concordance is legally defensible. “Find-A-Black-Doctor” has served as a platform for Black, Indigenous, and Persons of Color (BIPOC) to locate providers who can offer them the best holistic treatment. However, some see this as discrimination against white-majority physici...

It’s that bright new shiny object few seem to manage to resist: artificial intelligence (AI). Here at RACmonitor and Monitor Mondays, we have been reporting on how this disruptive technology has been altering the compliance landscape. And we will continue that reporting. AI is rapidly reshaping healthcare auditing and compliance, and as organizations move toward greater claim visibility and AI-dri...

Introducing FOCUS (Fraud Oversight through Careful Use of Statistics) .  The U.S. Department of Justice (DOJ) has launched a new initiative in response to the surge in False Claims Act qui tam filings by data miners. Today, roughly 45 percent of DOJ cases involve FCA data miners. You and your team will learn the inside story of this new initiative along with news of two significant data miner-init...

Healthcare compliance has entered the machine-learning era, and most organizations have not yet noticed.  Providers are using artificial intelligence (AI) to generate documentation, surface reimbursable conditions, and tighten coding workflows. Regulators and payers are using AI to detect abnormal patterns, flag statistical outliers, and identify documentation that does not align with expected cli...

Documenting and coding sepsis has challenged virtually everyone in healthcare ever since Sepsis-3 redefined the condition in 2016 as a “life-threatening organ dysfunction due to a dysregulated host response to infection.” Meanwhile, ICD-10-CM still maintains the older Sepsis-2 language of sepsis (SIRS/Systemic Inflammatory Response Syndrome due to infection, without organ dysfunction) and severe s...

The recent U.S. Supreme Court decision in Chiles v. Salazar doesn’t really close the case – but it also doesn’t really leave it open.  The 8-1 decision, in which the nation’s highest court ruled that a Colorado ban on so-called “conversion therapy” for juveniles was unconstitutional, is subtle, complex, and unnerving; the American Psychological Association issued a statement noting that it was “de...

Artificial intelligence (AI) is clearly here to stay – it’s now an integral part of healthcare. From coding and clinical validation to payer denials and appeals, AI is often a form of power upon which decisions are made by providers, payers, and auditors. You and your team should be aware of the several so-called healthcare “sherpas” available to interpret vast amounts of AI-generated data, among...