Monitor Mondays

Monitor Mondays

Join Chuck Buck every Monday when he welcomes RACmonitor contributing editors and special guests for the latest regulatory audit news and information from CMS, OIG and OMHA. And gain valuable context and perspective that can only be found when you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: https://event.webcasts.com/starthere.jsp?ei=1235505&tp_key=eae2082467... Show More

Episodes

Patient mortality is closely monitored. If a patient dies, the hospital wants to be sure the documentation accurately portrays the acuity of the patient, with all diagnoses, so that when the risk of mortality is calculated with the complex algorithm used by federal agencies, it demonstrates that the death was not unexpected, and is not indicative of poor-quality care. 

Reporting the lead story during this episode of M... Read more

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Direct or indirect past affiliation with an individual the Centers for Medicare & Medicaid Services (CMS) deems to be a bad actor could trigger revocation from Medicare.

The new rulemaking this so, 52 CFR, Section 424.519, Disclosures of Affiliations, authorizes CMS to deny or revoke enrollment based on disclosures of certain affiliations the agency determines to pose an undue risk of fraud, waste, or abuse.
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Giant healthcare insurer Optum has been in the news this week, and the news isn’t particularly favorable.

The results of a study published last week by Science revealed what researchers identified as a "significant racial bias" in Optum’s algorithm, which reportedly undervalues the healthcare needs of black patients. Although Science didn’t mention Optum by name, other news organizations have confirmed that it... Read more

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A federal court on Tuesday found that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced payments for hospital outpatient services delivered outside of hospitals in outpatient provider-based settings. The Centers for Medicare & Medicaid Services (CMS) could appeal the court’s decision on its site-neutral payment rule for hospital outpatient services. Score one for hospital... Read more

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Acts of Congress plus regulatory cuts by the Centers for Medicare & Medicaid Services (CMS) are estimated to reduce federal payments to hospitals by $256.6 billion from 2010 to 2029, according to a study released this week and commissioned by the American Hospital Association (AHA) and the Federation of American Hospitals.

Reporting on this developing story during this edition of Monitor Mondays is former CMS offi... Read more

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There have been recent media reports of layoffs and pay cuts among the ranks of those working in the nation’s skilled nursing facilities (SNFs) as a result of the new Medicare reimbursement model from the Centers for Medicare & Medicaid Services (CMS): the Patient-Driven Payment Model.

Reporting on these new changes during this edition of Monitor Mondays will be Toby S. Edelman, senior policy attorney for the Cent... Read more

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October 7, 2019 30 min

The Centers for Medicare & Medicaid Services (CMS) reportedly will collect information from hospitals about the prices they pay for drugs through the 340B discount program.

How will the information gathered by CMS be used, moving forward? And why is this action being taken by CMS? The agency has a history of attempted cuts to 340B reimbursement; the most recent such action by CMS occurred last December, after whic... Read more

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As expected, the Governor of Virginia, Ralph Northam, along with six managed care organizations (MCOs), have been named as defendants in a federal lawsuit filed on Wednesday, claiming that more than a dozen of the state’s Medicaid behavioral and mental healthcare providers had their agreements terminated by the MCOs without cause.

The suit was filed by the Potomac Law Group.

During this edition of Monitor M... Read more

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Other segments to appear during the live broadcast include the following:

  • RAC Report: Healthcare attorney Knicole Emanuel reports our lead story on the mass terminations of behavioral healthcare providers in Virginia. Emanuel has also been at ground zero in Richmond this past week, representing the aforementioned association there. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.... Read more

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  • Time is running out for skilled nursing facilities (SNFs). Come Oct. 1, 2019, time will be a thing of the past for such providers, as there will be a new payment methodology for SNFs: The Patient-Driven Payment Model (PDPM). Under PDPM, reimbursement for Medicare Part A patients in SNFs will be driven by patient condition, rather than by therapy minutes provided. Documentation is crucial to avoid a Recovery Audit Contractor (RAC... Read more

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    September 9, 2019 30 min

    Do you know the statutory and regulatory requirements to avoid jeopardizing payment for you and your skilled nursing facility (SNF)?

    You need to know because the Recovery Audit Contractors (RACs) and other contractors are reviewing SNF referrals. Reporting our lead story is physician and attorney John K. Hall, founder of the Aegis Firm. Hall reviews such statutory and regulatory requirements while also making recommen... Read more

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    Despite an order from the U.S. District Court for the District of Columbia for the federal government to reduce the backlog of Medicare appeals, the requirements for victory in front of an Administrative Law Judge (ALJ) remain the same.

    During this edition of Monitor Mondays, David Mullens, a California healthcare attorney, will address some of those fundamentals.

    Other segments to appear during the podcast... Read more

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    Two suicides, and a provider-driven into bankruptcy – and all because two ex-employee criminals looking for some fast cash lied to the state under the pretext of being whistleblowers tipping off Medicaid auditors, creating a cascade of unbelievable tragedy.  

    RACmonitor Editorial Board member, investigative reporter, and New York attorney Edward Roche returns Monitor Mondays with this exclusive story about a durable medica... Read more

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    Obtaining an injunction in federal court to lift a suspension of access to Medicare or Medicaid funds is rare, according to healthcare attorney Knicole Emanuel. 

    As she was preparing to file such an injunction in federal court recently, the prepayment review suspension was lifted. Emanuel, a partner in the Potomac Law Firm and a regular panelist on Monitor Mondays, reports on the possible reasons that might explain su... Read more

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    The Center for Medicare Advocacy (CMA) is reporting news about a new payment structure for home care, noting that such a plan is likely to adversely affect a hospital’s ability to acquire home care services for some patients. One of the factors to determine the payment to a home care agency for an episode of care is the origin of the patient, with two rates – one for the community, and one for the institution – and obviously, th... Read more

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    Reports of payer abuse continue unabated, and among the worst offenders cited by physician advisors are Aetna, Humana, and UnitedHealthcare.

    Case in point: When a physician advisor recently challenged an Aetna medical director about an observation payment, the medical director didn’t have an answer, but retorted by simply saying “whatever is in our contract.”

    This is but one example of Medicare Advantage (M... Read more

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    There was a time when therapy documentation was the focus of Recovery Audit Contractor (RAC) audits. 

    Under the Patient-Driven Payment Model (PDPM), however, reimbursement for Medicare Part A patients being treated in skilled nursing facilities (SNFs) will be driven by patient condition, rather than therapy minutes. And this creates a target-rich opportunity for auditors, because certain documentation can easily lead ... Read more

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    An older physician, practicing family medicine for 46 years, opens his door one day and finds an individual who says he works for the U.S. Department of Justice (DOJ), demanding to see medical records.

    In short order, the agent leaves the premises with charts, and later, the family physician finds himself facing the prospect of a trial by jury that the DOJ is demanding to quantify civil monetary fines and penalties. W... Read more

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    Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, has raised the anxiety levels of healthcare providers with her blog post on May 2, 2019. With an ominous warning, Verna said that the RAC ADRs will be guided by the volume of claims a provider submits based on an undefined “type” of a claim. Does this signal that observation claims could be reviewed simply based on the volume of claims?  Reporting... Read more

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    Under siege by policymakers, the controversial 340B drug discount program appears to be widely embraced by its 1,300 member hospitals that participated in a recent national survey. 

    Moreover, the survey revealed that members are using savings to provide critical services and access to care to patients with low incomes and those living in under-served rural communities. Reporting on this survey results and the import of its... Read more

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