Monitor Mondays

There have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS): the Patient-Driven Payment Model. Reporting on these new changes during this edition of Monitor Mondays will be Toby S. Edelman, senior policy...

The Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program. How will the information gathered by CMS be used, moving forward? And why is this action being taken by CMS? The agency has a history of attempted cuts to 340B reimbursement; the most recent such action by CMS occurred last...

As expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause. The suit was filed by the Potomac Law Group. During this edition of...

Other segments to appear during the live broadcast include the following: RAC Report: Healthcare attorney Knicole Emanuel reports our lead story on the mass terminations of behavioral healthcare providers in Virginia. Emanuel has also been at ground zero in Richmond this past week, representing the aforementioned association there. Emanuel, a member of the RACmonitor editorial board, is a partner...

Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM). Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to avoid...

Do you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)? You need to know because the Recovery Audit Contractors (RACs) and other contractors are reviewing SNF referrals. Reporting our lead story is physician and attorney John K. Hall, founder of the Aegis Firm. Hall reviews such statutory and regulatory requirements while...

Despite an order from the U.S. District Court for the District of Columbia for the federal government to reduce the backlog of Medicare appeals, the requirements for victory in front of an Administrative Law Judge (ALJ) remain the same. During this edition of Monitor Mondays, David Mullens, a California healthcare attorney, will address some of those fundamentals. Other segments to appear during t...

Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable tragedy.   RACmonitor Editorial Board member, investigative reporter, and New York attorney Edward Roche returns Monitor Mondays with this exclusive st...

Obtaining an injunction in federal court to lift a suspension of access to Medicare or Medicaid funds is rare, according to healthcare attorney Knicole Emanuel.  As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons...

The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the...

Reports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare. Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.” This is but one example of Medicare Ad...

There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits.  Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documenta...

An older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records. In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary f...

Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on...

Under siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey.  Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey res...

U.S. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health Committee, appears to be ready to shepherd his 165-page draft legislation on surprise balance billing for a vote next week.  In their push to get legislation prohibiting such billing through before the August recess, both the House and Senate have held hearings in the past two weeks on the various approaches to the problem. Those hear...

Most likely your facility has been hit with claim denials for providing emergency department level-of-care coding. Such denials are not new, and in fact, RACmonitor and Monitor Mondays have been reporting about these denials for a number of years.  But how can you and your team effectively deal with them? What tools and techniques are available?  During this edition of Monitor Mondays, John K. Hal...

Daniel Levinson, former head of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), will make his first broadcast appearance on Monitor Mondays since his announced retirement earlier this year. During his 15-year stint as the nation’s top healthcare watchdog, Levinson oversaw investigations into controversial health issues, including what was described as the la...

The fight is on, and combatants are sparring over how to implement a legislative ban on surprise balance billing.  In recent congressional testimony, providers, payers, and hospitals have clashed on how to keep patients from being stuck with huge expenses, with each side blaming the other for being intransigent. One of the major issues is how out-of-network doctors should be reimbursed, and at wha...

A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program.  U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association...

Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and...

The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid. More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have s...

News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing. Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albri...

New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA. Other segments to...

The Centers for Medicare & Medicaid Services (CMS) recently announced that 800 hospitals will be penalized this year for yielding poor results in the Hospital-Acquired Condition (HAC) Reduction Program, including 110 hospitals that are being penalized for the fifth year in a row (the HAC Reduction Program has only been in existence for five years).   The Code of Federal Regulations does not al...