Monitor Mondays

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...

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...