Monitor Mondays

Not unexpected but widely feared among healthcare providers, regulations setting 340B ceiling prices and establishing civil monetary penalties for drug manufacturers that knowingly and intentionally exceed those limits were delayed for the fifth time, until 2019, by the Trump Administration in a final rule published on Tuesday, June 5 in the Federal Register. As the dust settles, America’s rural h...

“Literally billions of dollars a year are being extorted from healthcare providers due to a system of rules, regulations, and guidelines that are not outdated, but just plain wrong,” writes senior healthcare analyst Frank Cohen, director of analytics and business Intelligence for DoctorsManagement in the current edition of the RACmonitor e-News. Cohen joined the Monitor Mondays broadcast to make h...

The subject of total knee replacement (TKR) continues to reverberate. In this edition of Monitor Monday, Lori O’Hara, the lead of the ADR, appeals and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, will offer the perspective of a long-term care provider. Her position is that a TKR patient either needs medical oversight or they do not. The ques...

The Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally issued by the outgoing Obama Administration in January 2017. It was formally published on Monday. National Correspondent Timothy Powell reported our...

The dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear to be experiencing relief not typically associated with other proposed rule changes. For them, the proposals from CMS for FY 2019 reflect som...

The problem begins like a blip on the radar screen: a curious anomaly that gradually grows more menacing. That is what Andrew Hughes, MD, and Charles Locke, both at Johns Hopkins, are noticing: an uptick in denials related to level of care provided versus the level of care billed. The majority of the denials arise when documentation indicates that a patient is "stable for downgrade" and...

Could non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors? While physicians reportedly represent nearly a million targets for audits, add in another couple of hundred thousand nurse practitioners (NPs) and physician assistants (PAs) and target acquisition becomes that much richer. And in their minds,...

Facebook CEO Mark Zuckerberg faced two days of grilling by Congress last week to address data misuse in the wake of revelations that millions of Facebook users had their private information given away to political consulting firm Cambridge Analytica in the run-up to the 2016 Presidential election. Zuckerberg testified before Congress that about 87 million users had their Facebook data taken withou...

Judge James E. Boasberg of the United States District Court for the District of Columbia has ordered the American Hospital Association (AHA) to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the Administrative Law Judge (ALJ) level. Reporting this developing story is healthcare attorney Andrew Wachler, Esq., managing partner at Wachler and Associates. The...

Telemedicine, considered to be an electronic lifeline for rural healthcare, is a rapidly growing sector of health care in the United States that has recently gone through a significant expansion. Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac's report on Telemedicine, is attorney Dale C. Van Demark, a partner at McDermott Will &...

Diving deep into the datasphere, senior healthcare analyst Frank Cohen comes up for air in order to report on a new approach he and his team of data experts have developed to predict the likelihood of an audit. While he claims that his team is not yet predicting billing errors, he does report that many of the variables being used to do so can also be used to forecast audits. During this episode Co...

Patients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful of not having their visits covered. Former ED physician-turned healthcare consultant Erica Remer, herself an Ohioan, reports on this developing s...

RACmonitor was founded in 2008 to provide news and information for healthcare providers on the emergence of the government’s Recovery Audit Contractor (RAC) program. From a Centers for Medicare & Medicaid Services (CMS) demonstration in that year, and continuing to the national rollout in 2010 (coincidentally, the year of Monitor Mondays’ national debut), we have been reporting on activities n...

"Anthem Blue Cross Blue Shield (BCBS) was set to implement a new processing edit with regard to the use of Modifier 25, effective March 1, 2018, but things didn't go as planned," reports Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS), as well as the president of coding and billing services and a partner at DoctorsManagement, L...

"The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians," reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. "These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does...

Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility? Mary Beth Pace, vice president of care management at Trinity Health and the special guest on this edition of Monitor Mondays, frames the co...

Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor Mondays, when whistleblower attorney Mary Inman reports on an ongoing  qui tam  action under the federal False Claims Act through which a relator a...

On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? Many of these electronic records are self-populated. So, what happens if you undergo a Recovery Audit Contractor (RAC) audit and are accused of wrongdoing? Offering insight int...

Healthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called Star Ratings, which are ultimately published on the C...

“We have been slammed with Medicare Advantage DRG audits,” wrote Sandra from Indiana during last week’s Monitor Mondays broadcast. We asked RACmonitor national correspondent J. Paul Spencer with DoctorsManagement to investigate this issue for this week's episode. Will there be more of these audits? Do these represent low-hanging fruit for auditors? Stay tuned. The episode rundown also include...

Monitor Mondays host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2018 during this edition of the weekly internet broadcast: Duane Abbey, PhD Janelle Ali-Dinar, PhD Nancy Beckley, MS, MBA, CHC Frank Cohen, MPA William Dombi, Esq. Knicole Emanuel, Esq. Ronald Hirsch, MD, FACP, CHCQM Angela Phillips, PT Timothy Po...