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 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...

Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fruit to be ripe for harvesting. While the Centers f...

As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread,  telehealth gained a foothold in America’s healthcare system, but that too is being subjected to audits. Medicare Advantage (MA) plans can tend...

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.   In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS),...

It has been more than 10 years since Richard Bagnall filed suit against Kathleen Sebelius, in her role as Secretary of the U.S. Department of Health and Human Services (HHS). Since then, the case has been recaptioned several times, and bounced back and forth between the U.S. District Court for Connecticut and the U.S. Court of Appeals for the Second Circuit. But the class-action suit, now known as...

In a terse, matter-of-fact announcement, the U.S. Department of Health and Human Services (HHS) is promising “significant enforcement” if providers have not complied with rules surrounding the Provider Relief Fund (PRF). This time, HHS is focusing on whether hospitals that received PRF payments complied with the surprise billing provisions of the PRF terms and conditions. Providing an early defens...

Medicare Advantage audits and spinal procedures relative to the Inpatient-Only List are two outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

These complimentary special edition podcast from RACmonitor features Chuck Buck and John Zelem, MD as they review on-demand webcasts as well as preview upcoming webcasts. Dr. Zelem offers a unique physician perspective as he explains to listeners key learning objectives from these educational webcasts. Visit RACmonitor.com to view more informational webcasts

A growing number of drug manufacturers are imposing unlawful limits on 340B discounts, according to a newly released report by 340B Health. Currently, up to 13 such companies “just say no” to discounts for prescription drugs sold to safety-net hospitals and dispensed through community pharmacies. During the next live edition of Monitor Mondays, reporting on the findings of this new report released...

For many third-party Medicare auditors, the only rules they follow are their own, substituting personal preference for regulatory realities – and all in the name of claim denials. Every day in nearly every American hospital, health system, or physician practice, some dedicated healthcare professional asks, “how could they do this to us?” There is a rightful place for Medicare auditing. But too oft...

The story first broke here on RACmonitor, when investigative reporter Edward M. Roche wrote about a case of double-dipping: the act of an auditor sampling and extrapolating against the same set of claims. As Roche explained in his exclusive RACmonitor article, the practice is like receiving two traffic tickets for a single instance of running a red light. The practice doubles the amount of recoupm...

It’s an amazing spectacle being played out on network television news, talk radio, and cable news outlets: the tug-of-war between the Biden Administration and the Supreme Court. So, the question remains: when is a mandate not a mandate?   The back-and-forth over the Centers for Medicare & Medicaid Services (CMS) vaccine mandates for a wide range of healthcare providers has reached a conclusion...

Public schools and facilities will be closed. Church bells will chime, while a number of flags will fly at half-mast.  Because in 1983, former Republican President Ronald Reagan proclaimed that the third Monday of January would forever be observed as Martin Luther King Jr. Day. This coming Monday, Jan. 17, Monitor Mondays will honor the slain civil rights leader with a special report recognizing e...

With the calamitous year of 2021 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future, on America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system for months or even years to come. With so many major changes expected to take place in 2022, you need t...

The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe. The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its features. For example, Medicare home health is movin...