Monitor Mondays

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 Nuclear Medicine & PET Coder .  Listen in to find out why this textbook could be a great addition to add to your essential library.

While the pandemic may have shielded healthcare providers from intrusive recoupment audits, the auditing break was but temporary. Starting in August of 2021, UPIC, TPE, RAC and other audits started back up and the contractors had a lot of catching up to do. At the same time, the administrative law judges were under enormous pressure to get the backlog of cases completed by the end of 2022. The res...

According to the U.S. Department of Justice, pharmaceutical giant Biogen will pay $900 million to settle a lawsuit that alleged the company gave doctors kickbacks to encourage them prescribe its drugs. The settlement resolves a lawsuit filed and litigated by former Biogen employee Michael Bawduniak against Biogen under the qui tam or whistleblower provisions of the federal False Claims Act. Famed...

Beware of enforcement action by the Centers for Medicare & Medicaid Services (CMS) for noncompliance of the Hospital Transparency Rule which took effect January 2021. The rule requires hospitals to make public—in machine readable files—prices for certain items and services. Failure to comply could result in fines as in the case of two Georgia hospitals. Make no mistake. CMS is laying down the...

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 CT/MR Coder .  Listen in to find out why this textbook could be a great addition to add to your essential library.

Provisions in the newly enacted Inflation Reduction Act represent some of the most significant changes to the healthcare system that have taken effect in the past decade. Maureen Testoni, president and CEO of 340B Health, will review some of the new law’s drug pricing elements. They include provisions for Medicare to start negotiating the prices it will pay for certain drugs for the first time in...

A national debate is raging across America involving providers and payers. The vexing issue is of medical necessity—and the search for consensus on a definition for this simple yet complicated issue.  During the next live edition of Monitor Mondays, Tim Brundage, MD will set the table for a robust discussion. Also on the rundown, the growing presence of private equity firms in healthcare. Given th...

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 Peripheral & Cardiology Coder .  Listen in to find out why this textbook could be a great addition to add to your essential library.

The warning was shot across the bow of Medicare Advantage Organizations (MAOs). The U.S. Department of Health and Human Services (HHS) Office of Inspector (OIG), in a report to the Centers for Medicare & Medicaid Services (CMS) raised concerned that MAOs could be denying prior authorizations requests in an attempt to increase profits. CMS agreed to the report and, on Aug. 3, issued new guidanc...

The public health emergency caused by Covid-19 compelled the U.S. Department of Health and Human Services to loosen the regulations to fund more telehealth services, and these "temporary" policies may be extended.  But what many may not know is that the United States has been experimenting with telehealth for 122 years, since the turn of the previous century, according to Edward M. Roche...

Although the “Inflation Reduction Act (H.R. 5376)” is still alive and headed to President Biden’s desk for his signature, there are provisions, deep inside the proposed legislation that will lower health care and prescriptions drug costs and could impact beneficiaries of some government-sponsored health insurance plans. During the next live edition of Monitor Mondays, physician and attorney Dr Joh...

Without admitting guilt, a Florida health system entered into a $20 million settlement under the False Claims Act with the U.S. Department of Justice (DOJ) to resolve allegations that it made donations to increase Medicaid contributions. The whistleblower filed the suit alleging that the system made improper cash donations to a local charity in a scheme to increase the system’s Medicaid funding. A...

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 Essentials of Interventional Radiology Coding .  Listen in to find out why this textbook could be a great addition to add to your essential library.

Like unwanted mushrooms bursting forth from your lawn, the Zone Program Integrity Contractors (ZPICs) appear to be on steroids. Their audits are aggressive disruptors in the vast auditing landscape in which providers continue to provide care and bill for the services they provide. In fact, the recent uptick in their audit activities is in the Medicaid arena. UPICs— the Centers for Medicare & M...

The recent decision by the Supreme Court to invoke the major questions doctrine to nullify an agency regulation in the case of West Virginia versus the Environmental Protection Agency seems to indicate the court’s trend toward increasingly strict interpretation of statutes. The possibility that new, or even well-established, regulations may be overturned means that healthcare regulation could chan...

Are commercial payers too big to fail? Do they operate with the sense of infallibility? Case in point: UnitedHealthcare Group, which according to its earnings report, posted $4.1 billion in profits in the fourth quarter of 2021. Is the playing field level between payers and providers?  For example, during the review of rejected claims does UnitedHealthcare or any private company such as this 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 Cardiac Rhythm Management Coder .  Listen in to find out why this textbook could be a great edition to add to your essential library.

“Good enough for government work,” was once the saying among cynical factory workers. And yet today in healthcare, precision in Medicare statistical analysis really matters. If overpayments are found, then the extrapolation recoupment number will go up; if underpayments are found, the extrapolation will go down. Listen and learn during the next live edition of Monitor Mondays when RACmonitor inves...

Medicare Advantage Audits, Establishing Medical Necessity to Ensure Payments, and the Two-Midnight Rule are three outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

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 Coding Essentials for Laboratories .  Listen in to find out why this textbook could be a great edition to add to your essential library.

Stranger than fiction are the reports coming from providers complaining of inconsistent and often contradictory reasons given for claim denials, leading to recoupment and the possibility of Medicare revoking privileges of participation in federal health programs – and this at a time of shrinking margins, rising inflation, budget cuts, and staff shortages. Little wonder that America’s hospitals, he...

Denials by payors for hospital claims continue to mount. Hospitals should take every opportunity to have a denial overturned – and an oft-neglected method is with a peer-to-peer call for a concurrent denial. A physician advisor can dedicate time and resources to accomplish it, but what do you do when the payor insists on only speaking with the attending physician? Since this is a recurring issue w...

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 Coding Essentials for Infusion & Injection Therapy Services .  Listen in to find out why this textbook could be a great edition to add to your essential library.

Nearly $3 billion in expected recoveries have surfaced in the spring 2022 Semiannual Report to Congress by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). As reported by RACmonitor’s Mark Spivey, the OIG report also provides an overview of the watchdog’s activities from Oct. 1, 2021 through March 31, 2022.  During the next live edition of Monitor Mondays,...

The 2022 audit landscape is rife with pitfalls and quicksand, trapping unsuspecting hospitals, health systems, and physician practices into a financial quasi-death spiral. And now, there’s another major disruptor: Condition Code 44, which continues to confound providers and revenue cycle professionals. Even though the Recovery Audit Contractors (RACs) have been held at bay, there are new audits ta...