Monitor Mondays

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...

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...