Monitor Mondays

Three whistleblowers brought a durable medical equipment (DME) provider to its knees.

In two separate cases, the whistleblowers targeted Exactech, a manufacturer of total knee replacement (TKR) systems, resulting in a settlement of $8 million to resolve alleged violations of provisions of the False Claims Act (FCA).
Famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLP, will report ...

Healthcare compliance just shifted fundamentally.
Traditional whistleblowers who needed inside access are being replaced by artificial intelligence (AI)-powered relators who mine public datasets and flag statistical anomalies that could signal fraud.
The U.S. Department of Justice (DOJ) logged 979 qui tam cases in 2024, many of which were reportedly triggered by mathematical outliers, rather than insider tips. Government ag...

Consider this a wake-up call.

As artificial intelligence (AI) quietly becomes part of the audit trail, healthcare leaders must ask a new question: who’s reviewing the reviewers?

During the next live edition of the venerable Monitor Mondays broadcast, contributing editor Sharon Easterling will break down why auditing AI tools are no longer a tech issue – they’re a documentation integrity and compliance priority.

Although this is an imp...

The Unified Program Integrity Contractors (UPICs) are household names in healthcare compliance.

But their track record tells a troubling story, according to senior healthcare analyst Frank Cohen. These Medicare fraud enforcement contractors are using controversial extrapolation techniques that providers successfully challenge over 60 percent of the time on appeal.

Cohen, who will be the special guest during the next live edition of M...

There just might be a reign of terror being experienced at many of America’s hospitals and health systems. Professionally delivered patient care apparently seems to be getting hijacked by auditors compelled to deny claims of omission.

Aided by the Centers for Medicare & Medicaid Services (CMS) and abated by auditors private and public, the lingua franca appears be an entanglement of descriptors, namely “inpatient versus outpatie...

Although the lawsuit was filed by a pharmacist in New Mexico, a federal judge in New York has ordered CVS Omnicare to pay $949,000 to settle a False Claims Act (FCA) case.

According to news sources, the Pharmacy Benefits Manager (PBM) allegedly prescribed drugs to individuals in long-term residential facilities that were not supported by valid prescriptions and then submitted claims for reimbursement for those prescriptions to Medic...

Federal legislation has been introduced that is intended to help the beleaguered 340B Health organization via an effort to ban pharmaceutical companies from restricting access to the drug pricing discount program of the same name, through community and specialty contract pharmacies.

Reporting this lead story as well as other updates from Congress and the Trump Administration during the next live edition of Monitor Mondays will be Ma...

The rugged audit landscape has changed – and not for the better.

Today, there are more potential pitfalls and traps to capture the unprepared and impact them with huge fines and possible incarceration. In fact, the Centers for Medicare & Medicaid Services (CMS) has erected a legal fortress to protect their audit process. It’s not the same old ballgame – it’s a new one, with lots of new players.

It’s also why the producers of Moni...

The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for the 2026 fiscal year has been released.

Tucked inside the Proposed Rule from the Centers for Medicare & Medicaid Services (CMS) is the agency’s recommendation to phase out the Inpatient-Only List (IPO) over the course of the next three years.

Reporting the lead story on this development during the next edition of Monitor Monday...

It’s a Medicaid Madness mess.

For many years, Medicaid has been providing support for America’s most vulnerable populations. But now, Medicaid finds itself as a pawn, being manipulated for political gain between two opposing forces: those who view the program as a means to an end to reduce government spending, and those who hold the opposite point of view.

Who will be the winners and losers? During the next live edition of the venera...

Looking back and looking ahead, we must reckon with a major shift in America’s judicial landscape: the elimination of the so-called Chevron Deference. Last year, at about this same time, physician and attorney Dr. John K. Hall was the special guest here on Monitor Mondays, and he began his segment explaining the legal concept.

Now, more than a year after the U.S. Supreme Court’s landmark decision overturning 40 years of judicial pre...

The Transparency in Coverage (TiC) Final Rule represents one of the most significant regulatory shifts in healthcare pricing since the implementation of the Patient Protection and Affordable Care Act.

During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will walk you and your team through the comprehensive labyrinth of changes.

Recent enforcement developments, including President Trump’s Executive Or...

Call it a trifecta, triumvirate, or the Triple Crown of 2025.

“Fraud, waste, and abuse” is the current triple-negative buzzword in America’s lexicon. And it’s being used to describe lots of things. But when that phrase is used by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), what does it actually mean?

You’ll learn during the next live edition of Monitor Mondays.

That’s when senior healthcar...

Clinical denials by payers for sepsis continues. The problem: the definition of the enigmatic condition does not meet their propriety definitions.
Enter Dr. James Kennedy, who will be the special guest during the next live edition of the long-running Monitor Mondays broadcast. Dr. Kennedy will report on his recent conversations with the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, in w...

The nation’s Medicaid program has seen better days. Recently, the federal government’s program to provide healthcare coverage to America’s low-income and vulnerable citizens was used as a bargaining chip as congressional Republicans were in the throes of budget negotiations, facing the daunting task to pass what President Trump calls his “big, beautiful bill:” a package of tax breaks disproportionately favoring the wealthy and spen...

During the next edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will provide an update on a whistleblower case that some consider “beyond bad.”

You’ll learn why a Texas rheumatologist who was sentenced to 10 years in prison and three years of supervised release was ordered to forfeit more than $28 million, plus 13 real-estate properties, a jet, and a Maserati GranTurismo sports car.

...

Welcome to a strange new world.

Recent tariffs announced by the Trump Administration are likely to impact drug manufacturing, since many drug components are produced outside the U.S., in nations such as in India, giving rise to state laws. Many states limit overseas involvement relative to the Health Insurance Portability and Accountability Act (HIPAA). Florida, for example, prohibits the offshoring of certain patient data, requirin...

On the surface, it was the perfect scam: kickbacks to docs in exchange for public speaking engagements, in order to induce them to prescribe drugs.

That’s apparently what Gilead Sciences thought.

But a whistleblower blew the whistle, and Gilead admitted to paying hundreds of thousands of dollars to high prescribers of their HIV drugs to serve as speakers at programs at luxury restaurants.

Famed whistleblower attorney Mary Inman, partn...

Once again, the venerable 340B Drug Pricing Program finds itself in the crosshairs of critics – this time, from the U.S. Congress.

Recently, Sen. Bill Cassidy (R-La.), ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, released a report outlining his office’s investigation into the program.

During the next live edition of Monitor Mondays, 340B Health CEO Maureen Testoni will return to the broadcast ...