Monitor Mondays

The United States Department of the Treasury’s Office of Foreign Assets Control (OFAC) recently issued an advisory on potential sanction risks for facilitating ransomware payments. It warned that entities, including hospitals, paying off ransomware demands might be subject to civil monetary penalties under the International Emergency Economic Powers Act (IEEPA). This action places hospitals in dan...

Providers that received payments from the federal Provider Relief Fund will be required to file reports demonstrating their compliance with the terms and conditions of those payments. Reporting on this, our lead story during the next live edition of Monitor Mondays, will be healthcare attorney Andrew Wachler, managing partner of Wachler & Associates. Mr. Wachler will report on anticipated “hot...

More payment cuts are being proposed by the Centers for Medicare & Medicaid Services (CMS) for next year, a move sure to impact the many hospitals participating in the 340B drug discount program, as described in the 2021 Medicare Outpatient Prospective Payment System (OPPS) Proposed Rule. Such proposed cuts are expected to reduce Medicare Part B drug payments to levels lower than in 2018, when...

The venerable topic of length of stay (LOS) has recently been generating buzz among healthcare professionals – so much so that we asked Stefani Daniels, founder and managing partner of Phoenix Management, to return to the weekly Monitor Mondays broadcast with an update, noting that the use of LOS has apparently declined. But is it still a valuable metric? And how might LOS be used today? This ques...

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently closed in on more than 345 defendants charged with participating in scams involving more than $6 billion in alleged losses to federal healthcare programs. The takedown occurred in September, according to the OIG. Of that amount, approximately $4.5 billion was associated with telemedicine schemes. The...

The Centers for Medicare & Medicaid Services (CMS) has moved to stop Medicare Advantage Organization (MAO)-hired subcontractors from issuing “pseudo-denials” that require pseudo-appeals before the MAO considers the denial formalized. The practice is reported to be extremely widespread and used against non-contracted providers: small, often rural hospitals that tend to be more vulnerable to the...

The recent announcement by the Centers for Medicare & Medicaid Services (CMS)  that it will be “ramping up” audits are quickly becoming a reality for providers across the country. Medicare Administrative Contractor (MAC), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), and Unified Program Integrity Contractor (UPIC) auditors are going full steam ahead, using data and...

The Centers for Medicare & Medicaid Services (CMS) will reimburse a greater number of relative value units (RVUs) associated with office-based evaluation and management (E&M) visits, the agency announced recently. In order to achieve budget neutrality, CMS will reduce the payment per RVU. With this change, CMS is allocating a larger proportion of its total spending to office-based physicia...

Unlike the Cold War arms race between the then-Soviet Union and the United States, today’s arms race is being fought before computer monitors, and in the deep corners of computer laboratories. And the weapon of choice: algorithms. This fierce fighting is taking place between auditors and providers, and the stakes are high: money. Lots of it. No stranger to chronicling the former Cold War arms race...

In recent weeks, several major pharmaceutical manufacturers have taken actions that could lead to narrowing the 340B Drug Pricing Program, which provides outpatient drugs to safety-net hospitals, health centers, and clinics at discount prices. The savings are invested in care for patients with low incomes, living in rural communities. The actions by Eli Lilly, Merck, and Sanofi are being challenge...

California is one of two states in the country that rewards whistleblowers for bringing forward information about private insurance fraud. A recent $24 million settlement with pharmaceutical giant Abbvie over the marketing of the company’s blockbuster drug, Humira, demonstrates the law’s effectiveness. The settlement agreement was reached last week following allegations that the company violated C...

The omnipresent coronavirus pandemic continues to upend lives, from mundane occasions like grocery shopping to long-planned space exploration missions. The pandemic is manifesting itself from the halls of Congress to the cubicles at Centers for Medicare & Medicaid Services (CMS) headquarters, to classrooms, theatres, homes, and places of worship, among other venues. On the next live edition of...

Center of Medicaid and Medicare Services (CMS) has been posting proposed rules for Medicare this past week. Already, CMS has issued the final rules for Inpatient Psychiatric Facilities, Skilled Nursing Facilities, and Hospices; and we are still awaiting the final rule on the Inpatient Hospital payment rules.   In light of these proposed rules we’ve asked two experts, Dr. Ronald Hirsch and Terry Fl...

While the battle cry of “defund the police” has emerged from Black Lives Matter activists following the death of George Floyd at the hands of Minneapolis police, could there also be sufficient reason for providers to advocate to “defund the Unified Program Integrity Contractors (UPICs)?” According to RACmonitor investivative reporter Ed Roche, UPIC auditors are attacking osteopathic medicine, and...

Two major storylines are discussed during this edition of Monitor Mondays, with the exclusive 60-minute broadcast to focus on the raging coronavirus pandemic and the imminent auditing of Medicare and Medicaid claims scheduled to begin Aug. 3, as directed by the Centers for Medicare & Medicaid Services (CMS). Joining the broadcast to report on the coronavirus will be Dr. John Foggle, Adjunct As...

Could Alexander VS. Azar really be over? This week's Monitor Mondays episode we've called upon or resident healthcare attorneys Knicole Emanuel Esq., David Glaser Esq. and our guest host John K. Hall MD, JD to dissect and assess the complicated case. The case has been disorganized since the beginning, possibly leaving more questions than answers. This Monitor Mondays round table will ana...

Last week, pharmaceutical giant Novartis paid $51 million to settle a Massachusetts suit about patient copay waivers. The DOJ press release notes that this is the 14th settlement of this kind to come from the Boston area. In related news, the Government brought a suit against Regeneron alleging that the company had a scheme of very well calculated charitable giving that steered patients to its mac...

The advent of the COVID-19 pandemic in the United States has generated nearly 2.5 million positive diagnoses, nearly 125,000 deaths – and dozens upon dozens of instances of modern-day snake-oil salesmen seeking to profit amid all of the chaos. Presenting the lead story during this edition of Monitor Mondays is Edward M. Roche, who will describe the various ways in which federal authorities are loo...

Don't let your guard down, post COVID-19 respiratory failure denials are on the horizon. Andrea Taylor from Enjoin reports why we aren't seeing denials yet and tips for appeals and waivers. Other segments featured during the podcast include: RAC Report: Healthcare attorney Knicole Emanuel, files the Monitor Mondays RAC Report. SDoH Report: Ellen Fink-Samnick reports on the National Healt...

Welcome to the new normal. You and your team continue to be challenged by consequences of the coronavirus pandemic, dealing with PPE shortages, along with confusing and oftentimes contradictory guidance from the Centers for Medicare & Medicaid Services (CMS). And now, we look onward – toward the audit horizon, and looming denials for COVID-related care. You need to be aware of ongoing payor ex...

Faced with rising numbers of COVID-19 cases, one hospital struggled to find adequate medical/surgical beds due to the challenges it had with discharging COVID patients. With a strong desire to address the need for surge capacity and to meet patient needs for inpatient rehabilitation, the challenge was met by the team at Henry Ford Macomb Hospital in Michigan, as you’ll learn during this edition of...

New York City-based RACmonitor investigative reporter Ed Roche returned to Monitor Mondays to report on developments in contact tracing: one of the newest tools in the fight to contain the deadly novel coronavirus that causes COVID-19. A hefty amount of money is being invested in contact tracing, including the development of new automated tools. But Roche reports his concern that some of the model...

Long-term care providers nationwide are seeking to identify ways to mitigate the uncontrolled spread of the COVID-19 virus amid vulnerable populations. Case in point: “drop teams” of physicians, infection preventionists, and nurses that could be deployed to any post-acute care space that was felt to be at risk. After seeing an outbreak at LifeCare Center in Kirkland, Wash., physician leadership an...

While much of today’s healthcare news is righty focused on the efforts to stave off the global coronavirus pandemic, there is other news to report – and Monitor Mondays will have a complete wrap-up on all of it during the next edition of the weekly Internet radio broadcast, while also looking ahead. And given the tendency of the Centers for Medicare & Medicaid Services (CMS) to issue waivers a...

Pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the U.S. Department of Health and Human Services (HHS) has allocated $50 billion to providers and other healthcare facilities in the form of a one-time payment, which does not need to be paid back. The payment comes with terms and conditions that recipients must follow, however, including permissible uses for the payment –...