Monitor Mondays

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 “...

Hospitals routinely measure, analyze, and track adverse patient harm events, collecting information about and reporting on certain types of such events in order to meet the Centers for Medicare & Medicaid Services (CMS) program and state legal requirements.

Prior work plans of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) revealed that hospitals reported few harm events to state reporti...

Across America, in sprawling university teaching facilities and in picturesque rural hospitals, administrators are dealing with a powerful tool called statistical extrapolation.

When auditors say that they’re using statistical “sampling” to review your Medicare claims, what they are often doing is using extrapolation – which could take what might appear to be minor discrepancies in your billing and turn them into major financial obl...

During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medicare home health payment model, Medicare Advantage (MA) claim denials in post-acute car...

Evoking the age-old adage of having “skin in the game,” a Phoenix, Arizona couple last month entered a plea of guilty to one of the largest healthcare frauds in U.S. history.

The couple pleaded guilty to criminal charges involving the submission of $1.2 billion in fraudulent claims to Medicare, Medicaid, and other insurers for wound care procedures. The husband-and-wife team have agreed to pay more than $600 million in restitution a...