Monitor Mondays

Coinciding with National Breast Cancer Awareness Month (October), RACmonitor investigative reporter Edward M. Roche recently went to the laboratories of Memorial Sloan Kettering to investigate one of the most exciting scientific developments of the decade. Roche, who was among the first to introduce the healthcare compliance world to algorithms, artificial intelligence (AI), and “smart” hospitals,...

The Centers for Medicare & Medicaid Services (CMS) is on record saying that Medicare Advantage (MA) payers must follow the Two-Midnight Rule as of Jan. 1, 2024. Yet, it has been reported by multiple hospitals that their MA plans have said their lawyers tell them that they do not have to follow the CMS directions on the Rule relative to inpatient status, claiming their contracts govern their re...

It’s little wonder that we will be reporting on artificial intelligence (AI)during the next live edition of Monitor Mondays. We were among the first to report on algorithms in claims auditing. But now, with so much attention being paid by the general news media to AI, its role in healthcare is gaining even greater attention and traction. So, during next live edition of our weekly Internet radio br...

The United States spends more money on healthcare than any other country in the world. In 2021, U.S. healthcare spending reached $4.3 trillion. Medicare, which insures seniors, is America’s largest national health program, and therefore, it can and should be compared to its counterpart in other countries. So, how does the United States stack up? How do outcomes in the United States compare for pat...

The fall season is just about here. Colorful autumn leaves will be becoming ubiquitous, like claims denials and audits. And in this season, now is the time to “git ‘er done.” And Monitor Mondays is the place to do it. In preparation, following the long Labor Day weekend, RACmonitor producers of Monitor Mondays have enlisted the services of some of the most trusted and respected names in regulatory...

First there was COVID-19, which seemed to have torn a gaping hole in our nation’s patchwork quilt of care facilities. Add to this the rising costs of everything that touches healthcare, and now the growing list of Chapter 11 bankruptcies rippling through nursing homes and other facilities that provide care for America’s seniors. But will the tentacles of this lengthening financial crisis reach dow...

Broadcast segments will also include these instantly recognizable features: Monday Rounds: Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds. The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors. Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his tr...

Information technology has revolutionized many industries, including healthcare. “Smart” hospitals promise vast increases in productivity, and are being designed as integrated IT platforms linking together technology, patients, and providers in a complex web of interaction. But are the promised advantages of smart hospitals tangible, or are there a number of factors that may inhibit providers from...

The Centers for Medicare & Medicaid Services (CMS) FY2024 Inpatient Prospective Payment System (IPPS) Final Rule, posted on Aug. 1, reveals changes to the MS-DRG, CMS Hospital Acquired Conditions, and CMS Inpatient Quality Reporting Program affecting inpatient revenue cycles, quality reporting, and reputations essential to hospital operations. There are plenty of audit hazards. And that’s why...

The Government Accountability Office (GAO) is recommending expansion of the Medicaid Recovery Audit Contractors (RACs) program, to include auditing of payments made to managed care organizations (MCOs), according to a GAO report released in June. Launched in 2011 as a consequence of the Patient Protection and Affordable Care Act (PPACA) by the Centers for Medicare & Medicaid Services (CMS), th...

There is a buzz swirling within the healthcare auditing community. And thanks to RACmonitor investigative reporter Edward M. Roche, the news is buzzworthy. According to Roche, a legal team has developed two arguments that can be used by healthcare providers in federal court after the Administrative Law Judge (ALJ) process is completed. One argument is based on constitutional rights, while the othe...

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to remedy Medicare Part B pay cuts made to 340B hospitals by issuing a lump-sum repayment to affected facilities. Last year, the U.S. Supreme Court ruled that those cuts, implemented by CMS from 2018 through most of 2022, were unlawful. Consequently, CMS proposed to offset the refunds by reducing payments for non-dru...

Although the 21st Century Cures Act was enacted in 2016, many hospitals today continue to struggle with effective implementation of its provisions and the goal of preserving patient access to medical records. Seven years later, however, meaningful guidance regarding its enforcement is here. One of the provisions requires developers not to engage in information blocking. Now that the guardrails are...

At least 1.3 million Medicaid enrollees have been disenrolled as of June 20, according to the Kaiser Family Foudation (KFF) “Unwinding Tracker.” This estimate could be an under-count, KFF admits, due to state recordkeeping details. Yet the major issue looms on the horizon: what will happen to those who have lost their Medicaid benefits? Could a tsuansmi of patients without health insurance soon ap...

“Hospitals may be the most complex organizations in the world,” writes Edward M. Roche, scholar, United Nations consultant, and RACmonitor investigative reporter. “They are tasked with improving patient outcomes, controlling costs, and meeting sustainable environmental goals.” Roche, who will be the featured panelist during the next live edition of Monitor Mondays, believes that hospitals, in thei...

Healthcare organizations often face staffing shortages in their revenue cycle, adding to the pressure of ensuring proper claims processing. The Centers for Medicare & Medicaid Services (CMS), U.S. Department of Justice (DOJ), and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) have increased audits to reduce improper payments, using predictive modeling and...

This week, a disgraced Elizabeth Holmes was seen in media clips walking in the company of two unidentified men. Evidently, Holmes, who was convicted of fraud for her blood-testing start up, Theranos, turned herself in at a minimum-security prison in Texas to begin an 11-year prison term. All this media coverage raises the question: how easy is it to run afoul of the government regarding a wide ran...

Why the confusion and the apparent uptick in denials by Managed Care Organizations (MCOs) for skilled nursing facility (SNF) transfers? Returning to report on this vexing topic during the next live edition of Monitor Mondays will be Ben Kartchner, MD, a physician advisor who will join the broadcast to present the final installment in his two-part series being produced by RACmonitor and Monitor Mon...

Medical necessity denials for skilled nursing facility (SNF) transfers by Managed Care Organizations (MCOs) are increasing at an astonishing rate. The reason seems to be a lack of understanding of the difference between skilled and non-skilled care. During an exclusive two-part series being produced by RACmonitor and Monitor Mondays, Ben Kartchner, MD will delve into this complex topic that is gen...

Your medical staff office just notified you that a physician has been performing procedures without privileges for the past five years. No, it doesn’t happen all the time. But what should you do? Physician and attorney Dr. John K. Hall will walk you through the considerations and help you understand how much revenue might be in jeopardy during the next live edition of Monitor Mondays. Broadcast se...

Hospital utilization and billing are notoriously challenging concepts for providers and case management staff because they frequently boil down to two, often conflicting points of view: what can be done per the rules, regulations, and contracts, and what should be done to provide the most effective care for a patient?  In a world where process standardization is imperative to maintain health syste...

The beleaguered False Claims Act, which traces its origins to the Civil War, came before the Supreme Court this past Tuesday, when the Court heard oral arguments in a consequential and closely watched case involving one of the Government’s most effective tools for fighting healthcare fraud.  Specifically, the issue is whether and when a defendant’s contemporaneous subjective understanding or belie...

Recent highly publicized advances in artificial intelligence forecast the elimination of at least 30 percent of the healthcare workforce (probably more), including all generalist physicians. The astonishing scalability of information technology suggests that one to three data centers will be able to deliver medical advisory services to the entire population of the United States, according to Edwar...

This year, as in past years, the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only List continues to confuse and bewilder so many healthcare professionals. And it’s little wonder: in 2021, CMS removed 500 surgical procedures from the List, only to reinstate most but not all of the procedures for 2022. Today, most Medicare and Medicaid plans follow the CMS Inpatient-Only List. But n...

It’s back: the Three-Midnight Rule. Created with the nation’s 1965 enactment of Medicare, the Rule provided that patients needed to have at least three consecutive midnights of inpatient care in an acute hospital setting before being admitted to skilled nursing facility (SNF). And then came the COVID-19 pandemic and the federal Public Health Emergency (PHE), and the rule was waived. Now, as the PH...