Monitor Mondays

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...

Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not present. Reporting on these all-too-common and unwel...

They take no breaks. Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trusted weekly news and information Internet radio broa...

2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior.  The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and does it change the potential for audit risk?  J...

In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims. The decision is likely to have serious ramifications, to the tune of tens of billions of dollars. It’s been estimate...

The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits. Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the low-hanging fruit created when administrators, phys...

Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries. Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn the extent of recent auditing activities, listen to...

Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight.  Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation.  Adding insult to injury is a new ruling handed down by the 5th Circuit Court al...

The COVID-19 pandemic might have subsided somewhat, but in the eyes of the Centers for Medicare & Medicaid Services (CMS), it is anything but over, as the agency continues to treat providers as if it were still surging. In order of priorities, CMS is starting to push Targeted Probe-and-Educate (TPE) audits, according to healthcare attorney Andrew Wachler. He reports that his firm is starting t...

SPECIAL GUEST Edward Roche, JD, PhD Director, Scientific Intelligence, Barraclough NY LLC ALSO FEATURING Matthew Albright; Knicole Emanuel, Esq.; Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP; David Glaser, Esq.; and Ronald Hirsch, MD, FACP, CHCQ RACmonitor investigative reporter Ed Roche is intimately familiar with what he describes as the blatant abuse directed at healthcare providers by overzea...

Six major U.S. drug manufacturers are refusing to provide 340B discount pricing for outpatient drugs sold to safety-net hospitals, community health centers, and public health clinics when those drugs are dispensed in community pharmacies. Will it take an act of Congress to intervene in this ongoing battle to restore 340B discounts and refund overcharges? Maureen Testoni, J.D., President and CEO of...

If your facility is considering submitting an amended claim request for a higher-weighted diagnosis-related group (HWDRG), be aware: the Centers for Medicare & Medicaid Services (CMS) has the authority to have your amended claim reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). And that alone could open up Pandora’s Box. Reporting our lead story du...

There are lists upon lists of hospital rankings. But there’s one list you’ll certaintly want your hospital to avoid. A report from Johns Hopkins University has revealed that many of America’s top 100 hospitals are using predatory tactics to pursue lawsuits against patients. Highlighting this list are government hospitals as well as nonprofit health systems called out for hounding patients to colle...

UnitedHealthcare is the latest insurer to join the growing lineup of payors that want to second-guess patients and deny payment for emergency department (ED) services after they’ve been rendered. As reported here on Monitor Mondays last week, UnitedHealthcare plans to extend no coverage or limited coverage to ED claims, retroactively – including any claims the giant insurer deems non-emergent. Our...

Are your physicians providing detailed documentation as they adhere the 2021 Evaluation and Management (E&M) Guidelines? Frank Cohen, senior healthcare analyst and director of business intelligence for DoctorsManagement, is concerned that they might not be – which, he believes, squarely puts them in an uphill battle, defending themselves from quality audits and potential malpractice suits. And...