Monitor Mondays

In response to the devastation caused by Hurricane Debby, now Tropical Storm Debby, the Centers for Medicare & Medicaid Services (CMS) has announced additional resources and flexibilities to support the affected states of Florida, Georgia, and South Carolina. Following President Biden’s emergency declarations and U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra’s Pub...

The U.S. Department of Justice (DOJ) has a new whistleblower reward initiative called the DOJ Corporate Whistleblower Awards Pilot Program. The Program, which seeks to fill gaps left by existing whistleblower reward programs, incentivizes whistleblowers to bring tips to the DOJ about types of healthcare fraud not already covered by the False Claims Act (FCA). According to Monitor Mondays special g...

The Inpatient Prospective Payment System Final Rule for Acute Care and Long-Term Care hospitals in the 2025 fiscal year (FY) continues to generate interest from providers, payers, hospital administrators, vendors, and consultants. But what are the significant takeaways for stakeholders as they prepare for the government’s fiscal year, which begins Tuesday, Oct. 1, 2024? Standing by to report the l...

Denver-based DaVita Inc. has agreed to pay slightly more than $34 million to resolve allegations that it violated the False Claims Act (FCA). The U.S. Department of Justice (DOJ) reported in a news release that DaVita paid kickbacks to induce referrals to DaVita Rx, a former subsidiary that provided pharmacy services for dialysis patients, directing the payments to nephrologists and vascular acces...

Could the end be near for the administrative law judges of the Centers for Medicare & Medicaid Service (CMS). What about the Office of Medicare Hearings and Appeals (OMHA)? Could these entities be gone from the audit landscape? Case in point: the Supreme Court (SCOTUS) continues eviscerating executive powers. This time SCOTUS has limited the authority of administrative tribunals and the admini...

Have you ever wondered how professional movers carefully pack everything? From expensive china to precious crystal stemware, they seem to have a knack and knowledge for how to prepare. When it comes to healthcare, how safe is the transition from hospital to home if a patient cannot get the services they need at home when they are ready to transition? More and more, we are seeing challenges with ho...

For nearly four decades, a judicial principle known as “Chevron deference” has guided the federal courts as they reviewed litigation associated with federal agencies. Chevron deference allowed legislators to leave statutes somewhat vague, assuming that an agency full of government experts would sort out the details and promulgate effective regulation. But, according to a recent U.S. Supreme Court...

In a late-breaking press release, the U.S. Department of Justice (DOJ) announced late Thursday that the agency had charged nearly 200 individuals accused with involvement in various healthcare fraud schemes estimated at $2.7 billion. Charges were brought against nurses, physicians, and others in a national sweep, and it was estimated that more than $900 million in false claims were submitted to Me...

A recent federal court decision in New Jersey demonstrates the viability of a different kind of whistleblower – in this case, a privately defrauded party. The most common type of a whistleblower under the False Claims Act (FCA) tends to be a corporate insider who sees fraud committed against the government by their employer or a company they work with, and generally after many, many attempts at in...

Artificial intelligence (AI) is fast becoming a fixture in healthcare revenue cycle management (RCM), where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision. During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Rames...

They’re looking for fraudsters, going on the prowl for bad actors, as revealed in the latest semi-annual report to Congress compiled by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In this latest report, the government watchdog identified more than $2.76 billion in expected recoveries and receivables. Providing analysis and context for the OIG report re...

Most healthcare investigations by the U.S. Department of Justice (DOJ) result in settlements. Many times, the complete details of the settlements in underlying government cases are not fully disclosed. But sometimes, a provider ends up at trial. And when that happens, it often offers insights into what it takes to get hit with hefty fines – and possible prison time, if you lose the case. During th...

A deep dive into microbiology can reveal an up-close look at the cells that make up organs of the human body – and corresponding cancer treatments that leave no trace of damage. The science of medicine appears to be moving at the speed of light lately. But will new healthcare technologies be audit-proof? Monitoring these escalating changes and their impact on America’s delivery of healthcare servi...

Two recent settlements to resolve allegations of violating the False Claims Act – both involving the virulent COVID-19 – are the latest in a series of actions that will be reported on during the next edition of Monitor Mondays by famed whistleblower Mary Inman, who also notes that her company, Whistleblower Partners, LLP, is poised to announce another major case pending the unsealing of court docu...

The arms race is heating up. On one side there are healthcare providers, and on the opposing side, an army operated by the auditors. Who will be the winners and losers? Are you safe? And how do you protect your facility from claim denials and takebacks, especially when auditors are using artificial intelligence (AI)? RACmonitor investigative reporter Edward M. Roche will return to Monitor Mondays...

Do you have peer-to-peer (P2P) discussions? Are they useful? Are they valuable? And how do you know? Our own physician and attorney, Dr. John K. Hall, will offer his unique take on the value of P2P interactions and how you should measure it during his appearance as Guest Panelist on the next upcoming edition of Monitor Mondays. Broadcast segments will also include these instantly recognizable feat...

Like seasoned harbor pilots navigating tugboats through natural and manmade hazards, physician advisors each day face the daunting task of guiding their hospitals through a labyrinth of Medicare rules and regulations. Reporting on those conditions during the next edition of Monitor Mondays will be the vice chair of the recently concluded national conference of the American College of Physician Adv...

Artificial Intelligence (AI) software is now in the “hype phase” of adoption. It promises to increase the efficiency of medical audits. But also, AI is being touted as being able to handle much more data, examine many more cases, and instantly make decisions regarding medical necessity or inadequate documentation. The number of audits can be doubled, tripled, quadrupled. Why take samples for revie...

The recent $37 million settlement against Cigna regarding enhancing risk adjustment factor (RAF) scores —along with related litigation by the U.S. Department of Justice (DOJ)— highlight the aggressiveness of the federal government to crack down on entities for non-compliant billing practices. During the next live edition of Monitor Mondays, Dr. James Kennedy will unpack the challenges entities hav...

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit that accuses Martin’s Point Health Care, along with five other providers in other states, of defrauding the government of more than $300 million, pertaining to allegations that the providers inflated patients’ risk scores to obtain higher payments to which they were not entitled from the government’s military health plan. Broa...

Since its launch in January 2021, the Hospital Price Transparency Rule from the Centers for Medicare & Medicaid Services (CMS) has been a vexing issue for many of America’s hospitals. Despite enforcement efforts from CMS, implementation for many providers has been onerous – so much so that when the latest requirements were issued by CMS, one could imagine provider executives simply giving up,...

Many of America’s hospitals continue to be challenged as it pertains to complying with the requirements from the Centers for Medicare & Medicaid Services (CMS) for implementing the agency’s rule on hospital price transparency. And that is why RACmonitor and Monitor Mondays are producing a three-part series, in collaboration with ClaraPrice, to help providers fix this vexing problem, including...

America’s hospitals are currently facing a critical challenge: a flood of patients placed under observation, leading to lost revenue and operational disarray. Amid the confusion, questions arise. Even seasoned bedside physicians struggle with uncertainty in determining patient status upon admission. But fear not! There is hope in this chaotic landscape, unlocked by empowering the bedside physician...

There was a time when everyone in healthcare compliance and revenue cycle management was scrambling to implement the Hospital Price Transparency Rule. Now, nearly four years later, it’s back. The Centers for Medicare & Medicaid Services (CMS) 2024 Final Rule for Price Transparency marks the biggest change to the rule requirements since it initially took effect in January of 2021. The new manda...

What happens if the Supreme Court of the United States (SCOTUS) dismantles decades of government agency discretion? Recent cases at SCOTUS indicate that this could happen. But what would be the consequences? During the next live edition of the long-running Internet radio broadcast Monitor Mondays, RACmonitor’s own physician and attorney Dr. John K Hall will consider the ramifications of the demise...