Monitor Mondays

The global COVID-19 pandemic has presented a multitude of logistical challenges to healthcare providers across the country and beyond. But few are as daunting as the protocols utilization management (UM) directors are being asked to implement regarding patient status assignment. Delivering a riveting report from the front lines of the pandemic during this edition of Monitor Mondays, Stephanie Van...

“Although Office of Medicare Hearings and Appeals (OMHA) office space is closed to the general public, OMHA remains open for business with employees working under maximum telework flexibilities, per U.S. Office of Personnel Management guidance.” -OMHA website. Indeed, “OMHA hearings and appeals processing measures are proceeding as scheduled,” the notice reads. “Unless an appellant is notified dir...

Custodial admissions are problematic for hospitals under normal circumstances. But now, incredible demands placed upon facilities by COVID-19 create even more challenges, as you’ll learn during the next edition of Monitor Mondays – when Juliet Ugarte Hopkins, MD, will return to the broadcast as its special guest to report on the issues that are hampering efforts to keep hospital beds open for the...

The 1,000-bed USNS Comfort, a hospital ship that in the past has provided humanitarian relief around the world, is now anchored on Pier 90 in Manhattan to provide humanitarian relief as COVID-19, the illness caused by the novel coronarvirus, ravages New York City, now the epicenter of the pandemic. Also in New York City, the famed Jacob Javits Center has been converted to a 1,200-bed field hospita...

Waivers from regulations, dire shortages of ICU beds, and scarce personal protective equipment (PPE), including gloves, gowns, and masks, are all part of the new normal as the coronavirus (COVID-19) continues to generate global headlines, especially in the United States. Amid a cacophony of misinformation, providers and patients are searching for clarity in this fog of war. That time has come. Nex...

During this of Monitor Mondays, senior healthcare analyst Frank Cohen, a computational statistician, reports on how anecdotal thinking is not evidence-based thinking, and it is difficult to draw conclusions without having all of the information – noting that’s exactly what is happening right now, as America grapples with the coronavirus (COVID-19). Other segments to be featured during the live bro...

Converting Medicare patients from inpatient to outpatient status is a compliance issue. And hospitals need to know how to process the proper billing level of care for beneficiaries. Using their benefits correctly is a responsibility, since these patients rely on caregivers to advocate for them. To help navigate these potential audit traps, we asked Mary Beth Pace, vice president of care for Trinit...

Seldom does a week pass without news about a pharmaceutical giant engaged in corporate wrongdoing. This week, the feds announced that they had filed a complaint under the False Claims Act (FCA) against Mallinckrodt ARD LLC. The complaint alleges that the pharmaceutical company “avoided paying hundreds of millions of dollars in Medicaid rebates due to significant drug price increases” as a result o...

Contentious and confusing, the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule will become effective Jan. 1, 2021. On the surface, the requirements are straightforward: hospitals and health systems must make accessible all negotiated managed care rates in a machine-readable format, along with a list of 300 “shoppable” items –non-urgent, high-volume items and ser...

Like a destructive earthquake, recent news from The Chartis Center for Rural, documenting the accelerated rate of closures among rural hospitals, is sending shock waves through rural communities. As with the Richter scale, the closure of one rural hospital is likely to have an exponential impact on all rural health. And the stark reality is that, as of January 2020, a total of 120 rural health fac...

With a 30,000-foot view of rural healthcare policies and regulations emanating from Washington, D.C., Leslie Marsh still recognizes the importance of having boots on the ground, serving as the chief executive of Lexington Regional Health Center in Lincoln, Neb. Marsh, who also serves as vice president of board of directors for the ruralMED Health Network, addresses the ubiquitous Z codes and their...

The artificial intelligence (AI) arms race is heating up. The use of AI by healthcare providers responding to a wave of audits initiated by AI systems is an escalation. As the government continues to deploy AI systems in Medicare audits, providers will respond with their own counter-measures, also using AI. Reporting our lead story during the next edition of Monitor Mondays will be RACmonitor inve...

Practice Function, Inc., a unit of Allscripts Healthcare Solutions Inc., engaged in an "abhorrent" scheme to help a pharmaceutical company push its extended-release opioids, according to a news release posted on Monday by the U.S. Department of Justice. The company agreed to pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) soft...

What once appeared to be a legislative slam dunk is now mired in controversy, this time fueled by the recently formed coalition dead-set against the proposed use benchmark payments. The Coalition Against Rate-Setting considers the practice tantamount to price-fixing. What will happen next to the compromise legislation, which was hammered out with bipartisan congressional support? Matthew Albright,...

AmerisourceBergen, one of the nation’s largest pharmaceutical wholesalers, must turn over records to pension fund shareholders probing to determine wrongdoing by the drug distributor’s board for the company’s multi-billion-dollar legal exposure from the nationwide opioid crisis. AmerisourceBergen was already facing two congressional investigations, plus a Drug Enforcement Administration (DEA) prob...

2020 ushers in a formidable decade of healthcare regulations and a perilous audit landscape, populated with aggressive auditors who will be aided by artificial intelligence to review and deny claims. Decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert – and RACmonitor and Moni...

Join us for a unique look behind the scenes with long-time Monitor Mondays moderator Clark Anthony as he interviews many of our esteemed panelists from the last 10 years.

It’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare & Medicaid Services (CMS) included a reduction in the base payment rate of 8.01 percent in the Patient-Driven Groupings Model (PDGM) of the 2020 Home Health Prospective Payment System Rate Update. Returning to Monitor Mondays is William Dombi, president of the National As...

Rural hospitals are an endangered species in America, with extinction a real possibility.  In fact, the North Carolina Rural Health Research and Policy Analysis Center report that more than 120 hospitals have closed nationwide since 2005, with nearly 70 percent (or 83) of those closures occurring since 2010. Adding insult to injury is the recent announcement from the Centers for Medicare & Med...

Many hospitals are likely in the throes of preparing to implement the Centers for Medicare & Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, including how to reconcile the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The new rule becomes effective Friday, Nov. 29, 2019. “CMS has spent the last two years working on the IMPACT Act, an...

Patient mortality is closely monitored. If a patient dies, the hospital wants to be sure the documentation accurately portrays the acuity of the patient, with all diagnoses, so that when the risk of mortality is calculated with the complex algorithm used by federal agencies, it demonstrates that the death was not unexpected, and is not indicative of poor-quality care.  Reporting the lead story dur...

Direct or indirect past affiliation with an individual the Centers for Medicare & Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare. The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, w...

Giant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable. The results of a study published last week by Science revealed what researchers identified as a "significant racial bias" in Optum’s algorithm, which reportedly undervalues the healthcare needs of black patients. Although Science didn’t mention Optum by name, other news organizations...

A federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings. The Centers for Medicare & Medicaid Services (CMS) could appeal the court’s decision on its site-neutral payment rule for hospital outpatient...

Acts of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American Hospital Association (AHA) and the Federation of American Hospitals. Reporting on this developing story during this edition of Monitor Monda...