Monitor Mondays

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...

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...