Monitor Mondays

It’s the biggest healthcare story of the decade: up to 15 million individuals will soon be disenrolled from Medicaid, when the COVID-19 public health emergency (PHE) shuts down. Those who enrolled in Medicaid during the pandemic must re-enroll to keep their Medicaid coverage. Suddenly, your hospital could be overrun with uninsured patients. What’s being done about this issue, and what can you do?...

Imagine for a moment that the federal government, through one of its contractors, sends you money for services you don’t believe are covered benefits for a particular patient at your facility. But wait. Don’t react just yet. The best course of action might not be what you think, and it’s definitely not simple or straightforward, as you’ll learn during the next live edition of the long-running Moni...

Famed whistleblower attorney Mary Inman will return to the Monitor Mondays weekly Internet radio broadcast this coming Monday to report on a unique case in which a jury found that Precision Lens and its owner, Paul Ehlen, illegally paid kickbacks to ophthalmic surgeons to induce their use of the company’s products in cataract surgeries reimbursed by Medicare. The company was found to have submitte...

We at Monitor Mondays will begin a monthlong observance of National Doctors’ Day this coming Monday, March 6. Although the 90-year-old recognition of American physicians is March 30, during the next live edition of our weekly Internet radio broadcast we will recognize the contributions of Scott Ceule, MD, a physician advisor who, along with his team, helped create a transfer center at the Universi...

The U.S. Department of Justice (DOJ) reports that fraud against the U.S. under the federal False Claims Act (FCA) has amounted to $2.2 billion recovered in settlements and judgments for the 2022 fiscal year.    As in past years, FCA recoveries in the healthcare and life sciences industries continued to dominate enforcement activity in terms of the number and value of settlements, with healthcare f...

The concern is real. And it’s growing. Providers could incur False Claims Act (FCA) liability when care that is delivered crosses over from “worth less” to “worthless.” You need to know where to draw the line. And that’s why we asked physician and attorney John K. Hall to explain, during the next live edition of Monitor Mondays. Broadcast segments will also include these instantly recognizable fea...

What constitutes inpatient status? Should patient status be determined by guidelines or screening criteria? Or just the facts? Revisiting what is certain to be considered an evergreen issue, Dr. Andrew Markiewitz will return to report the lead story for the next upcoming live edition of Monitor Mondays to continue discussing the vexing topic of patient status. Dr. Markiewitz is expected to report...

Healthcare providers nationwide are facing menacing interactions with auditors that, like hungry predators, are looking at submitted claims for the slightest evidence of omission or commission as the justification to pounce. But it’s not so much the actual auditing as the long and wearisome journey of appeals – and the very real possibility of financial disaster. Although medical record auditing i...

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore! In this episode, Mary goes over the Respiratory Therapy All Access Pass , and why it is an important product for healthcare professionals. 

Never-before-seen data has revealed that Hierarchical Condition Category (HCC) risk scores could predict under- or over-coding – and it will be the primary topic of discussion during the next live edition of Monitor Mondays. That’s when senior healthcare analyst Frank Cohen will report on his findings. The HCC risk score is a relative measure of the average health (or lack of health) for a Medicar...

In May 2022, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a report claiming that 25 percent of Medicare patients experienced adverse events during their October 2008 hospital stay. “That’s a staggering number,” said John K. Hall, MD, in an email to RACmonitor. “So, what does it mean, and what should providers expect from other auditors and gove...

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore! In this episode, Mary goes over the Nuclear Medicine All Access Pass , and why it is an important product for healthcare professionals. 

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...

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore! In this episode, Mary goes over the Infusion & Injection All Access Pass , and why it is an important product for healthcare professionals. 

In October, after 18 months in the news cycle, Optum closed its controversial acquisition of Change Healthcare.  While the healthcare industry intensely watched the merger beat a challenge from the U.S. Department of Justice (DOJ) on antitrust grounds, that  news story was far from the only newsworthy acquisition that Optum has made.  With far less public discourse than the Change Healthcare acqui...

Are Medicare auditors similar to ancient hunting parties roaming the tundra for wild game? Are audits applied equally and randomly across all healthcare providers, or is there intelligent design directed by a  hidden network of influencers, working behind the scenes and shifting first to one area, then another? During the next live edition of Monitor Mondays, Edward M. Roche, RACmonitor’s investig...

Listen to Mary's Bookclub, where Mary summarizes the products you can find at the MedLearn online bookstore! In this episode, Mary goes over the Comprehensive Cardiology All Access Pass , and why it is an important product for healthcare professionals. 

We’ve all watched in awe as the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) began investigating the Medicare Advantage plans. Many were thinking, “it’s about time the payers get some of the heat providers feel.” But there’s something even better, according to most. That’s when the OIG investigates the government. During the next live edition of Monitor Mond...

Most healthcare providers are swimming in shark-infested waters these days, ever-watchful for dorsal fins that signal imminent danger.   At first there were the Recovery Auditors (RAs), created by the Centers for Medicare & Medicaid Services (CMS), to correct Medicare billing submitted by providers for services rendered to Medicare beneficiaries. And now, nearly two decades later, the RAs have...

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore! In today's episode, Mary explains the importance of Ultrasound Coder .  Listen in to find out why this textbook could be a great addition to add to your essential library.

Along the gulf shores of Mobile Bay in Alabama, at the crack of dawn you might hear shouts of jubilation from early risers there to witness flounder, soft-shell blue crabs, and gulf shrimp beach themselves due to the upward movement of oxygen-deprived bottom waters. The aftermath is a bounty of seafood on the sandy beaches, and hence the local dish known as “jubilee.” Yet when it comes to local he...

The Medicare Physician Fee Schedule Final Rule for 2023 includes a provision for telehealth services – this following the temporary expansion of telehealth to beneficiaries during the COVID -19 public health emergency (PHE) that began March 1, 2020. Once the temporary PHE waivers terminate, what are the plans the Centers for Medicare & Medicaid Services (CMS) has for covering telehealth servic...

Healthcare attorney Andrew Wachler is an audit warrior, with war stories that will make you cringe in absolute disbelief. And during the next live edition of Monitor Mondays, Wachler will tell some of these stories, sharing lessons to learn from his experience defending provider clients. He’ll report how failure to appeal a target, probe and educate (TPE) audit could establish a “pattern or practi...

Rumors, as they tend to sometimes, are spreading fast. Are there significant leadership changes coming within the largest Medicare Advantage (MA) plans for many beneficiaries in the mid-South region of the country? Spend time with Jennifer Bartlett, longtime systems coordinator at Infirmary Health System in Mobile, Alabama, and it becomes clear that there could be a whole new ballgame, with new pl...

DRG validation denials by Medicare Advantage (MA) plans have become a widespread and increasing concern for many hospitals. But these denials may be the result of a misapplication of standard diagnostic criteria by a reviewer. Now, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is turning the DRG validation denials back on MAs. The OIG recently published s...