Monitor Mondays

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...

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 Respiratory Therapy/ Pulmonary Function .  Listen in to find out why this textbook could be a great edition to add to your essential library.

The 2 MN Rule has been with us for several years but there still is confusion about what qualifies as inpatient. Condition Code 44 has been the corrective approach to inpatient status errors despite CMS’ warning that Condition Code 44 should not be used as a substitution for inadequate utilization management processes. Condition Code 44 can serve as a reflection that the utilization process is bei...

Johnson & Johnson, along with Gilead, are among the most recent pharmacy giants that have joined the list of others that are imposing restrictions on 340B drug price discounts to 340B hospitals. The latest information comes from a recent study conducted between December 2021 and March 2022 that reveals 16 other major pharmacies are flaunting the law – and their actions have doubled. Reporting...

2010 does not seem that long ago. It’s hard to believe we’re at Monitor Mondays broadcast No. 500 since then. But then again, let’s look at all we’ve seen change. Medicare started out with a one-midnight expectation for inpatient reimbursement. Then the Recovery Audit Contractors (RACs) moved in, showed us all the errors of our ways, and demonstrated that unrestrained denials could overwhelm the a...

Like fine wine, problem lists age very well. Too well, in fact. Such lists can remain in place for months, even years, without being updated. And questions can lead to conflicts and errors. Too often, problem lists simply languish, with unchanged patient encounter information. Moreover, even when a problem does appear on the problem list, it doesn’t necessarily signal that the provider addressed t...

With the growth of Medicare hospice services comes expanded oversight on claims and care quality. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has initiated a nationwide audit of hospice claims on the heels of multiple in-depth audits of such facilities. Unified Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) have joi...

How is one major hospital system reducing observation hours? Listen to the next live edition of Monitor Mondays to find out; that’s when Mary Beth Pace will return, by popular demand, to continue her compelling discussion on how she and her team at Trinity Health are taking steps to reduce the volume of observation hours. With her laser focus on patient care, Pace will report on how the Centers fo...

What are your observation volumes doing to your bottom line? How much care do these patients get compared to your inpatients? If your facility is like most facilities, the billing status does not dictate the care provided; it just dictates the reimbursement you can expect to obtain. Worse yet, it does not leverage the patient’s insurance benefits correctly.  Join us during the next live edition of...

The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center. Great topics. Great analysis. More great educati...

Too many times, and in too many cases, providers are being subjected to flaws in methodologies and calculations used by auditors that lead to recoupment demands and other penalties. Aided by ambiguously written rules from the Centers for Medicare & Medicaid Services (CMS), unscrupulous auditors are often able to pounce on unsuspecting providers, wreaking havoc on revenues and human resources....

The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned.   However, there are also so-called “technical denials,” in which real or alleged provider lap...