Monitor Mondays

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 ...

Nearly every day, on any news service, images of people being quickly led away is chilling as the current Administration continues its sweep of rounding up and deporting suspected illegal immigrants.

Thus, in this current climate of increased audits, investigations and scrutiny on immigration, it is essential that healthcare organizations sponsoring foreign nationals for employment, ensure that documentation, policies, and practices...

The fiscal year (FY) 2026 Inpatient Prospective Payment System (IPPS) proposed rule introduces significant reforms to hospital reimbursement, risk adjustment, and performance measurement.

Key changes include the Centers for Medicare & Medicaid Services (CMS) transition to HCC Version 28, the use of the Community Deprivation Index (CDI) for socioeconomic risk adjustment and expanded inclusion of Medicare Advantage data in quality...

A flurry of national news reports continues to document the large-scale restructuring taking place at the U.S. Department of Health and Human Services (HHS), where 10,000 jobs were reportedly slashed earlier this month, a move also impacting the workforce at the Centers for Medicare & Medicaid Services (CMS). An estimated 300 CMS workers are expected to be affected by this action, while NPR reported that the HHS teams focusing ...

A recent case, United States v. Junyi Liu, reveals how a $23 million fraud scheme exemplifies vulnerabilities in America’s healthcare system – as you’ll discover when senior healthcare analyst Frank Cohen joins the next Monitor Monday broadcast.

You’ll also learn about the challenges legitimate providers face when navigating complex regulations – and more about the government’s aggressive “pay-and-chase” enforcement tactics, plus wh...

No matter the approach one might take for debridement, wound care continues to be an attractive source for audits – they inevitably arise and fester. Case in point: Wachler and Associates, a prestigious law firm in Michigan, currently is representing clients in some 18 wound care audit cases.

That is why RACmonitor, producers of Monitor Mondays, has invited Andrew “Drew” Wachler, founder of Wachler & Associates, to be the specia...

National Doctors’ Day is actually Sunday, March 30, but the one-day nationwide observance is getting an early celebratory start during the next live edition of the venerable Monitor Mondays broadcast.

Joining our esteemed panelists will be three well-known physicians: Drs. Stephanie Van Zandt, Clarissa Barnes, and Juliet Ugarte Hopkins. And each doc will have an “open mic” during the 30-minute live Internet broadcast.

The long-runnin...

A clinical documentation integrity (CDI) professional who “knowingly … acts in reckless disregard of the truth or falsity of the information” may ultimately run into issues related to the federal False Claims Act (FCA).

The Medicare Fee-for-Service (FFS) Compliance Program on the Centers for Medicare & Medicaid Service (CMS).gov website lists several CMS compliance programs designed to educate and support Medicare providers in “...