Monitor Mondays

A clinical documentation integrity (CDI) professional who “knowingly … acts in reckless disregard of the truth or falsity of the information” may ultimately run into issues related to the federal False Claims Act (FCA). The Medicare Fee-for-Service (FFS) Compliance Program on the Centers for Medicare & Medicaid Service (CMS).gov website lists several CMS compliance programs designed to educate...

Hospitals routinely measure, analyze, and track adverse patient harm events, collecting information about and reporting on certain types of such events in order to meet the Centers for Medicare & Medicaid Services (CMS) program and state legal requirements. Prior work plans of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) revealed that hospitals repor...

Across America, in sprawling university teaching facilities and in picturesque rural hospitals, administrators are dealing with a powerful tool called statistical extrapolation. When auditors say that they’re using statistical “sampling” to review your Medicare claims, what they are often doing is using extrapolation – which could take what might appear to be minor discrepancies in your billing an...

During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medicare home health payment model, Medicare Advantage (...

Evoking the age-old adage of having “skin in the game,” a Phoenix, Arizona couple last month entered a plea of guilty to one of the largest healthcare frauds in U.S. history. The couple pleaded guilty to criminal charges involving the submission of $1.2 billion in fraudulent claims to Medicare, Medicaid, and other insurers for wound care procedures. The husband-and-wife team have agreed to pay mor...

Challenges in reimbursement, benchmarking, and quality reporting are being experienced in many American hospitals. Why is this problem arising? Our special guest during the next live edition of Monitor Mondays will have answers. Penny Jefferson, a seasoned healthcare professional who serves as the Director of Clinical Documentation Integrity (CDI) Services at the University of California at Davis...

Artificial intelligence (AI) is becoming as commonplace in healthcare as billing audits. It’s ubiquitous. And that is why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to explore the intersection of AI and healthcare. So, during the next live edition of the venerable live weekly Internet broadcast, Cohen will address key concerns for compliance professionals,...

Earlier this week, in the wake of the inauguration of President Donald Trump, a major announcement was made that some hope will lead to new advances in healthcare: “Stargate,” a private venture to build in the U.S. hyperscale data centers for artificial intelligence (AI). The strategic goal is to make the United States the world’s leader in AI. Larry Ellison, founder of the relational database com...

New York health insurer Independent Health and its former executive reached a settlement that will amount to up to $100 million with the U.S. Department of Justice (DOJ) and a whistleblower over False Claims Act allegations that they made Medicare members appear sicker than they really were to get more money from the government, a practice known as risk adjustment fraud. Betsy Gaffney, former CEO...

“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling them “Hirsch’s Heroes,” an annual tradition that bega...

Have you ever had your insurance company deny payment for your claim? Have you ever had your insurance company stall or deny a pre-authorization? How long did it take to get the authorization for the medication you’ve been using to keep yourself alive for the past few years? Was it maddening? During the next edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine the frust...

It’s raining recovery auditors. More denials. More grief. More lost revenue and more palpable anxiety. The seemingly unending war between payers – private and public – and providers continues unabated. The ubiquitous Two-Midnight Rule and the contentious subject of observation versus inpatient status have become an indelible part of America’s healthcare system. And that is why the producers of RAC...

$23 million: that’s the amount that the University of Colorado Health, also known as UCHealth, has agreed to pay to resolve False Claims Act allegations related to its seeking and receiving payment from federal healthcare programs for visits to its emergency departments. The university, headquartered in Aurora, was accused of falsely coding certain Evaluation & Management (E&M) claims subm...

As we continue to monitor and review the latest healthcare news, we are always pleased when word of a new study comes to our attention – especially when the study is within the purview of MDaudit. During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report the latest results of a new national study – and how the salient takeaway points could help you and your t...

Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements. For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials. During the next live edition of the venerable Interne...

Denials in healthcare are a problem. Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA). Hut reports that MA plans are classifying hospital stays as outpatient observation visits at a significantly higher rat...

A pediatrician under investigation related to accusations that she had engaged in sexual relations with a male patient, having lied about it when applying for another healthcare position, was recently sentenced for making false statements. In another case, a federal contractor agreed to resolve False Claims Act allegations in connection with a government contract related to its storage of unsecure...

Could you and your care team be at risk when you upgrade a patient from observation to inpatient simply because the patient passed a second midnight in the hospital, based on the Centers for Medicare & Medicaid Services (CMS) contentious Two-Midnight Rule? And what about the expectation? How does expectation enter this equation? And finally, what should be present to change that expectation? D...

The U.S. Department of Justice (DOJ) has reported that one of America’s largest urine drug-testing companies has agreed to pay $27 million to resolve allegations of unnecessary drug testing and illegal remuneration to physicians. The False Claims Act allegations resolved by this settlement were originally brought in three lawsuits filed by whistleblowers under the qui tam provisions of the False C...

A major drug company’s attempt to turn 340B drug pricing program discounts into rebates made big headlines in recent weeks. Maureen Testoni, president and CEO of 340B Health, will review how this potentially major upheaval came about, how 340B stakeholders responded, and how the drugmaker backed off after the federal government threatened it with massive penalties. This debate is by no means over....

As violent crime has trended slightly downward throughout the United States over the last year, a wound to this country’s collective psyche that appears reluctant to close is workplace violence in America’s hospitals. Reporting the lead story during the next live edition of Monitor Mondays will be special assignment contributor Dennis Jones, senior director of revenue cycle at Jefferson Health. Jo...

Oak Street Health, headquartered in Chicago and a wholly-owned subsidiary of CVS Health since 2023, has agreed to pay $60 million to resolve allegations that it violated the False Claims Act by paying kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street Health’s primary care clinics, according to a news release issued by the U.S. Department of Justice (DOJ). R...

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays. Pace, in making the statement, was referring to rules and regulations set forth in the Federal Register...

What’s wrong with this picture? With more than 10 years of the Centers for Medicare & Medicaid Services (CMS) Two-midnight Rule now behind us, one would presume that most healthcare professionals should know what determines an inpatient status. But some don’t. That is why RACmonitor has invited renowned physician and attorney Dr. John K. Hall to report on the requirements and risks associated...

A comprehensive new survey featuring responses from more than 1,500 U.S. patients reveals that they are not only frustrated by poor provider support, but also are experiencing tangible health setbacks – especially when waiting to refill prescriptions and being placed on hold while waiting to speak to a caregiver. Israel Krush, CEO and Co-Founder of Hyro, the healthcare vendor whose company sponsor...