Monitor Mondays

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...

When the U.S. Supreme Court overturned Chevron deference, it promised to restore judicial independence and limit agency overreach.  But in Medicare administrative proceedings, that promise remains unfulfilled.  Tune in to the next upcoming live edition of Monitor Mondays, when senior healthcare analyst Frank Cohen will report on his surprise when an Administrative Law Judge issued a categorical ru...

National Doctor’s Day will bring a double whammy this coming Monday when the venerable Monitor Monday continues its recognition of the occasion with a pair of featured speakers: Drs. Drew Updike and Christopher Boyle. The day of recognition took place on March 30, the date when Eudora Brown would place flowers on the graves of late physicians, starting in 1933. Historians are quick to note that th...

Artificial intelligence (AI) is becoming part of how clinical documentation is reviewed across healthcare, from coding and clinical validation to payer denials and appeals.  In many cases, AI is influencing decisions behind the scenes, even when it is not clearly visible. During the next live edition of the long-running Monitor Monday, the Internet broadcast produced by RACmonitor, Sharon Easterli...

Aetna is just the latest in a long list of healthcare entities to settle False Claims Act (FCA) allegations with a massive settlement. The insurer, one of the nation’s largest, recently agreed to pay $117.7 million to resolve a case involving purportedly inaccurate and untruthful diagnosis codes to increase payments.  That and other recent U.S. Department of Justice (DOJ) actions will take center...

Imagine machine learning and natural language processing deployed to audit claims. Today, it’s the new reality. Autonomous coding is dramatically altering the treacherous auditing landscape. So, how can you protect your facility from takebacks? How do you maintain coding excellence to remain compliant? Join this coming Monday, March 16 for the next live edition of the venerable Monitor Mondays Int...

Healthcare documentation is no longer written for a single audience. Today, the medical record must simultaneously meet federal regulatory requirements and the coverage expectations of individual payers. While these systems often overlap, they originate from different authorities and serve different purposes. One governs compliance and program integrity; the other determines whether services are a...

The Centers for Medicare & Medicaid Services (CMS) has launched a new initiative titled Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH). CRUSH is a sweeping fraud prevention program. In an official news release posted Thursday, CMS reported suspending $5.7 billion in suspected fraudulent Medicare payments, preventing $1.5 billion in DMEPOS (Durable Medical Equipment, Prosthe...

Prior authorizations among Medicare Advantage plans have drawn criticism and concern from patients, providers, lawmakers, and regulators. But hospitals and doctors are uniquely positioned to advocate for their patients’ access to and coverage for care. What’s necessary is the need to understand the rules of the process. And Medicare Advantage plans have many of them. During the next live edition o...

In a January 28 article, Dr. Ronald Hirsch verified that the Centers for Medicare and Medicaid Services (CMS) “has no problem” with the Aetna Severity Payment policy because it “meets the Two-Midnight Rule.”  However, there is more to consider than compliance with 42 CFR 412.3.  Federal regulations also state Medicare Advantage organizations must comply with Traditional Medicare laws including pay...

It’s raining RACs. The Recovery Auditor Contractors (RACs), together with an alphabet soup of other private and public auditors, are coming down hard on hospitals and physician practices, looking for omissions and errors in submitted claims. Then there are seemingly contradictory rules from the Centers for Medicare & Medicaid Services (CMS). It’s little wonder that providers are treading cauti...

There was a time when Relative Value Units (RVUs) felt like a stable currency – something you and others could take to the bank.  That was then. This is now. Then, productivity could be measured, compensation plans could be managed, and economic models could assume relative stability in physician work measurement. Recently, actions by the Centers for Medicare & Medicaid Services (CMS) – culmin...

While many of you were enjoying the holidays, Kaiser Permanente was back in the news. This time, another whistleblower case which resulted in an amazing $556 million settlement to resolve allegations that the giant provider/payer fudged on its Medicare Advantage risk adjustment. Reporting the lead story during the next live edition of Monitor Mondays will be Liz Soltan, a New York-based senior ass...

The Centers for Medicare & Medicaid Services (CMS) will block hospitals from performing certain interventions that are intended to change a child’s physical appearance to align an asserted sex identity. Reporting the lead story during the next live edition of Monitor Mondays will be independent physician consultant Dr. Drew Updike. More than four weeks since its last news broadcast, Monitor Mo...

Whistleblower attorney Max Volman will return to the next Monitor Monday broadcast to report the latest news about whistleblowers.  As we have learned, often “whistleblowers” are not insiders reporting wrongdoing; they tend to be outside the offending organization. Register now to listen to Max Voldman’s exclusive report. Broadcast segments will also include these instantly recognizable features:...