Monitor Mondays

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...

The implementation of generative artificial intelligence (AI) in the Electronic Health Record (EHR) is one of several hot-button issues to be explored during the next live edition of the Monitor Mondays, the long-running Internet broadcast produced by RACmonitor. Other high-level considerations to be reported include leveraging AI in regulatory compliance, creating physician notes from doctor-pati...

The Merit-based Incentive Payment System (MIPS) uses a composite performance score to determine if eligible physicians will receive a payment bonus, a payment penalty, or no payment adjustments. So, what’s the score for your physicians? Do they know? During the next live edition of the long-running Monitor Mondays, Leigh Poland, vice president of coding services for AGS Health, will report on why...

Auditors use the Comprehensive Error Rate Testing (CERT) study from the Centers for Medicare & Medicaid Services (CMS) as a way to target individual providers for potential recoupment. For example, if you get paid millions of dollars for some procedure codes or DRGs that have high error rates, it increases the likelihood that those specific codes and/or DRGs will be audited. Why? Because, stat...

What’s important to know about the Comprehensive Error Rate Testing (CERT) program from the Centers for Medicare & Medicaid Services (CMS) is that auditors rely upon the results to target specific providers for recoupment audits. The more you know about CERT and the study results, the better position you will be in when it comes to understanding both the general risk of an audit and the specif...

Will the World Health Organization (WHO) be given the power to impose restrictive pandemic measures on countries, including the United States? Will it be legally binding? What are the challenges and opportunities for healthcare providers in the United States, and how will this be enforced? The member states of the WHO have been working on a plan of action when faced with the next pandemic. Negotia...

No more eggnog. Toss the champagne bottles. The good times are over, and now it’s back to business. But not business as usual.  As the rest of the nation’s healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its last news broadcast, Monitor Mondays will return...

“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling them “Hirsch’s Heroes,” an annual tradition that bega...

RACmonitor investigative reporter Edward M. Roche, an intrepid regular monitor of America’s healthcare system, will return to Monitor Mondays for its next upcoming edition to report on how and why America’s healthcare system has tied itself into a Gordian Knot of complexity: interwoven strands of conflicting rules and regulations, different payments for the same services, and a cumbersome patchwor...

The annual 2023 MDaudit Benchmark Report has been published, and it is relevatory in its analysis of articial intelligence (AI) and its impact on payment and revenue integrity. According to the report, the primary topic of discussion for the next live edition of the long-running Monitor Mondays Internet broadcast, the implications of AI are immense when predicting its application to audit workflow...

To quote the titular lyrics of the song popularized by Frank Sinatra for his very first No. 1 hit, “it was a very good year.” The U.S. Department of Justice (DOJ) announced that more than $2 billion in False Claims Act settlements and judgments were reported in the 2023 fiscal year. According to the DOJ, government and whistleblowers were “party to 351 settlements and judgments,” the second-highes...

The Two-Midnight Rule was first announced 10 years ago, October 2013, by the Centers for Medicare & Medicaid Services (CMS). Even today, though, the Rule remains an ongoing source of confusion for physicians as well as revenue cycle and finance experts. However, it also will take on new importance, as CMS promises that Medicare Advantage (MA) plans will begin to follow the Rule in 2024. During...

Violence in America’s hospitals is an issue that is squarely on the minds of hospital administrators and staff. And the violence seen in our society has increasingly encroached into the medical workplace. This violence can be verbal, it can be physical, it can be disturbing, and it can be deadly. The escalation and prevalence of violence in hospitals has had a major impact on employees, patients,...

Congress and the Biden Administration continue to take a keen interest in issues related to prescription drug access and pricing. There is evidence of recent movement on Capitol Hill toward legislation aimed at addressing drug shortages affecting the healthcare system. The government also is implementing a plan Congress approved last year to lower the prices Medicare will pay for certain drugs. Fo...

So far in October, the U.S. Department of Justice (DOJ) has been very busy, securing settlements, pleas, and convictions ranging in value from $25 to $350 million. And just this month, DOJ announcements have featured settlements related to Anti-Kickback and Stark violations, as well as convictions in genetic testing schemes and guilty pleas for fraud involving unnecessary testing. During the next...