Monitor Mondays

Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fruit to be ripe for harvesting. While the Centers f...

As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread,  telehealth gained a foothold in America’s healthcare system, but that too is being subjected to audits. Medicare Advantage (MA) plans can tend...

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.   In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS),...

It has been more than 10 years since Richard Bagnall filed suit against Kathleen Sebelius, in her role as Secretary of the U.S. Department of Health and Human Services (HHS). Since then, the case has been recaptioned several times, and bounced back and forth between the U.S. District Court for Connecticut and the U.S. Court of Appeals for the Second Circuit. But the class-action suit, now known as...

In a terse, matter-of-fact announcement, the U.S. Department of Health and Human Services (HHS) is promising “significant enforcement” if providers have not complied with rules surrounding the Provider Relief Fund (PRF). This time, HHS is focusing on whether hospitals that received PRF payments complied with the surprise billing provisions of the PRF terms and conditions. Providing an early defens...

Medicare Advantage audits and spinal procedures relative to the Inpatient-Only List are two outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

These complimentary special edition podcast from RACmonitor features Chuck Buck and John Zelem, MD as they review on-demand webcasts as well as preview upcoming webcasts. Dr. Zelem offers a unique physician perspective as he explains to listeners key learning objectives from these educational webcasts. Visit RACmonitor.com to view more informational webcasts

A growing number of drug manufacturers are imposing unlawful limits on 340B discounts, according to a newly released report by 340B Health. Currently, up to 13 such companies “just say no” to discounts for prescription drugs sold to safety-net hospitals and dispensed through community pharmacies. During the next live edition of Monitor Mondays, reporting on the findings of this new report released...

For many third-party Medicare auditors, the only rules they follow are their own, substituting personal preference for regulatory realities – and all in the name of claim denials. Every day in nearly every American hospital, health system, or physician practice, some dedicated healthcare professional asks, “how could they do this to us?” There is a rightful place for Medicare auditing. But too oft...

The story first broke here on RACmonitor, when investigative reporter Edward M. Roche wrote about a case of double-dipping: the act of an auditor sampling and extrapolating against the same set of claims. As Roche explained in his exclusive RACmonitor article, the practice is like receiving two traffic tickets for a single instance of running a red light. The practice doubles the amount of recoupm...

It’s an amazing spectacle being played out on network television news, talk radio, and cable news outlets: the tug-of-war between the Biden Administration and the Supreme Court. So, the question remains: when is a mandate not a mandate?   The back-and-forth over the Centers for Medicare & Medicaid Services (CMS) vaccine mandates for a wide range of healthcare providers has reached a conclusion...

Public schools and facilities will be closed. Church bells will chime, while a number of flags will fly at half-mast.  Because in 1983, former Republican President Ronald Reagan proclaimed that the third Monday of January would forever be observed as Martin Luther King Jr. Day. This coming Monday, Jan. 17, Monitor Mondays will honor the slain civil rights leader with a special report recognizing e...

With the calamitous year of 2021 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future, on America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system for months or even years to come. With so many major changes expected to take place in 2022, you need t...

The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe. The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its features. For example, Medicare home health is movin...

The auditing never stops, and the pace is quickening. New issues, new audits. But what are the costs for hospitals seeking to avoid audits? In one of the most comprehensive reports of its kind ever offered, RACmonitor and Monitor Mondays will bring on board prescient thought leaders to define the contours of this deepening healthcare regulatory crisis. During the next edition of Monitor Mondays, o...

"It’s time to stop getting stuck thinking we have a square-peg-and-a-round-hole problem, and focus on the fact that 42 CFR codifies and makes it law that a Medicare Advantage plan, even though it has autonomy in its contract, cannot offer less benefits than Medicare. Medicare Advantage plans cannot have more restrictive guidelines than Medicare; they must at the very least adhere to the simpl...

The signs are ominous. New final rules have been published. All the auditors are there, ready to pounce. Warnings are being sounded. It’s a tsumani of audits. During the next live edition of Monitor Mondays, we’ll report on the latest news and most current updates, offering you our early warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consu...

Using artificial intelligence (AI), along with an uncanny ability to misinterpret rules, Medicare auditors – specifically, third-party auditors of Medicare Advantage (MA) plans – are ever-ready to pounce on healthcare providers. And too often, it’s like shooting fish in a barrel. The recent posting of three final rules will give auditors ample opportunity to search for more inadvertent errors on M...

The next three consecutive Monitor Mondays broadcasts will constitute an explosive series, exposing for the first time how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims. Learn about this outrageous behavior when RACmonitor investigative reporter Edward C. Roche presents the first edition of his three-part series that exposes wrongdoing that is...

Operating with virtual impunity, while relying on artificial intelligence, payor auditors have locked on to providers to deny claims that trigger audits. Acts of omission by providers are often deemed acts of commission in the eyes of auditors – and the audits often lead to recoupment. Even the slightest apparently innocuous action can trigger a cascade of negative reactions, including denials.  E...

Once suspended by COVID-19, claim audits are now back on the frontburner – Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Medicare Administrative Contractor (MAC) audits, plus Targeted Probe-and-Educate (TPE) audits are the new (or renewed) normal. It’s open season on providers, which is why, in large measure, the next live edition of Monitor Mondays will feature...

Big surprise. But not really. The Interim Final Rule (IFR) for the federal No Surprises Act, released last month, appears to offer bad news for out-of-network providers (OON), which does not come as a surprise to heathcare attorney Thomas Force, who will return to the Monitor Mondays broadcast. Force will explain, citing that the guidance is focused on what the bill defines as good-faith estimates...

The heat is on. As reported by RACmonitor, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) auditor, has started sending out documentation requests for short-stay inpatient audits. For targeted hospitals, Livanta will select 30 inpatient admissions of Medicare beneficiaries whose length of stay (LOS) was either zero or one day within the prior three mon...

Rampant auditing by Medicare Advantage (MA) plans is a constant occurrence, with notable cases being reported weekly by RACmonitor. To wit: the recent U.S. Department of Justice (DOJ) filing of a complaint in intervention in a case against Independent Health of Buffalo, New York and its coding vendor, DxID. And there’s the recent case of Sutter Health and its $90 million settlement in a MA risk ad...

As healthcare attorney Knicole Emanuel recently reported here on RACmonitor, in 2022 providers can expect a “frenzy” of audits –  although it seems to be happening already now, as some hospitals are executing crisis standards of care while coping with an influx of COVID-19 patients (namely, unvaccinated patients who have contracted the deadly Delta variant). The result is that many hospitals are o...