Monitor Mondays

New York health insurer Independent Health and its former executive reached a settlement that will amount to up to $100 million with the U.S. Department of Justice (DOJ) and a whistleblower over False Claims Act allegations that they made Medicare members appear sicker than they really were to get more money from the government, a practice known as risk adjustment fraud. Betsy Gaffney, former CEO of now-defunct vendor DxID, agreed to pay $2 million to resolve allegations she helped DxID mine patients’ medical records for diagnoses that risk-adjust, nudging doctors to approve them up to a year after the patient visits, all while pocketing up to 20 percent of the additional revenue generated for Independent Health by these unsupported diagnoses. Reporting the lead story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm Whistleblower Partners. More than four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here and in RACmonitor. Broadcast segments will also include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment. • Legislative Update: Cate Brantley, senior government affairs liaison for Zelis, will report on current healthcare legislation. Register now to listen to this exclusive news edition of Monitor Mondays; all this and more will be coming up at 10 a.m. EST on Jan. 13, 2024.

“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling them “Hirsch’s Heroes,” an annual tradition that began in 2015, Hirsch will reveal those to whom he has bestowed the esteemed honor during the next live edition of Monitor Mondays. Other broadcast segments will include these instantly recognizable features: • The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment. • Field Report: Phyisican and attorney Dr. John K. Hall is expected to file a field report on the recent Anthem Blue Cross Blue Shield proposal relative to its anethesia policy which the giant payer has since abandoned. • Legislative Update: Matthew Albright, chief leglistative affairs analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Have you ever had your insurance company deny payment for your claim? Have you ever had your insurance company stall or deny a pre-authorization? How long did it take to get the authorization for the medication you’ve been using to keep yourself alive for the past few years? Was it maddening? During the next edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine the frustration that modern health insurance has become – especially in the context of the recent fatal shooting of a prominent health insurance chief executive officer (CEO). Broadcast segments will also include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

It’s raining recovery auditors. More denials. More grief. More lost revenue and more palpable anxiety. The seemingly unending war between payers – private and public – and providers continues unabated. The ubiquitous Two-Midnight Rule and the contentious subject of observation versus inpatient status have become an indelible part of America’s healthcare system. And that is why the producers of RACmonitor have dedicated the next live edition of the venerable Monitor Mondays Internet broadcast to be the go-to source for the latest audit and regulatory news: a veritable feast of valuable information for you and your team to use. Broadcast segments will also include these instantly recognizable features: • Monday Rounds: Substituting for Dr. Ronald Hirsch will be Dr. Tripti Katari, who will be making her Monday Rounds. Dr. Katari is expected to report on updates on the American Medical Association (AMA), which she serves as Legislative Counsel. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Adam Brenman, senior healthcare legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

$23 million: that’s the amount that the University of Colorado Health, also known as UCHealth, has agreed to pay to resolve False Claims Act allegations related to its seeking and receiving payment from federal healthcare programs for visits to its emergency departments. The university, headquartered in Aurora, was accused of falsely coding certain Evaluation & Management (E&M) claims submitted to the Medicare and TRICARE programs. Reporting the lede story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners. Broadcast segments will also include these instantly recognizable features: • Monday Rounds: Dr. Ronald Hirsch, vice president of R1-RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Matthew Albright, chief legislative analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

As we continue to monitor and review the latest healthcare news, we are always pleased when word of a new study comes to our attention – especially when the study is within the purview of MDaudit. During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report the latest results of a new national study – and how the salient takeaway points could help you and your team as you grapple with the dynamic environment of America’s healthcare system. Broadcast segments will also include these instantly recognizable features: • Monday Rounds: Dr. Ronald Hirsch, vice president of R1-RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements. For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials. During the next live edition of the venerable Internet radio broadcast, Dr. Kartchner will complete his discussion as to how detailed clinical updates, assessments, and rationale for continued hospitalization can preemptively address payer scrutiny and reduce denials while optimizing reimbursement for patient care. Other segments during the weekly broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Denials in healthcare are a problem. Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA). Hut reports that MA plans are classifying hospital stays as outpatient observation visits at a significantly higher rate than traditional Medicare even though the rule is supposed to be applied the same way in both programs. And Hut believes the situation is likely to be getting worse because UnitedHealthcare is targeting provider coding while it seeks to bring down medical spending that has been higher than anticipated in recent fiscal quarters. Hut will be reporting this story during the next live edition of Monitor Mondays. He has more than 12 years reporting healthcare policy news and trends. Other segments during the weekly broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

A pediatrician under investigation related to accusations that she had engaged in sexual relations with a male patient, having lied about it when applying for another healthcare position, was recently sentenced for making false statements. In another case, a federal contractor agreed to resolve False Claims Act allegations in connection with a government contract related to its storage of unsecured personally identifiable information of Medicare beneficiaries. Recognizing that it’s not only a bad idea, but also a crime to lie to a government agency, Monitor Monday’s own attorney and physician Dr. John K. Hall will report on how your organization’s cybersecurity could put you at risk of false claims liability during the next live edition of the long-running Internet radio broadcast. Specifically, Dr. Hall will review these two recently resolved cases and offer tips to avoid liability. Other segments during the weekly broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Could you and your care team be at risk when you upgrade a patient from observation to inpatient simply because the patient passed a second midnight in the hospital, based on the Centers for Medicare & Medicaid Services (CMS) contentious Two-Midnight Rule? And what about the expectation? How does expectation enter this equation? And finally, what should be present to change that expectation? During the next live edition of Monitor Mondays, Ben Kartchner, MD, a prominent physician advisor, will thread the needle of this controversial regulation to give his perspective on how the two-midnight expectation can serve as your compass, helping you steer through regulatory challenges, ensure compliance, and prevent unnecessary denials. Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The U.S. Department of Justice (DOJ) has reported that one of America’s largest urine drug-testing companies has agreed to pay $27 million to resolve allegations of unnecessary drug testing and illegal remuneration to physicians. The False Claims Act allegations resolved by this settlement were originally brought in three lawsuits filed by whistleblowers under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government – and to share in any recovery. Reporting on this major story during the next live edition of Monitor Mondays will be famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLC. Other segments during the weekly Internet broadcast will include these instantly recognizable features: •Monday Rounds: Juliet Ugarte Hopkins, MD, will be making her Monday Rounds. •The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. •Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation. •Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

A major drug company’s attempt to turn 340B drug pricing program discounts into rebates made big headlines in recent weeks. Maureen Testoni, president and CEO of 340B Health, will review how this potentially major upheaval came about, how 340B stakeholders responded, and how the drugmaker backed off after the federal government threatened it with massive penalties. This debate is by no means over. The idea of imposing rebates in 340B is not a new one, and the concept has come back into prominence recently amid the ongoing implementation of the Inflation Reduction Act, which will have important effects on 340B. Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Folana Houston, assistant general counsel for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

As violent crime has trended slightly downward throughout the United States over the last year, a wound to this country’s collective psyche that appears reluctant to close is workplace violence in America’s hospitals. Reporting the lead story during the next live edition of Monitor Mondays will be special assignment contributor Dennis Jones, senior director of revenue cycle at Jefferson Health. Jones returns to his beat to continue his reporting of this issue. Among those healthcare professionals most at risk for workplace violence are nurses and those who work in emergency rooms. In fact, a 2021 study conducted by the Cleveland Clinic revealed that workplace violence tends to be four times more prevalent in healthcare than in other industries. Jones is expected to have more details on “Violence in America’s Hospitals.” Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Cate Brantley, senior government analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

Oak Street Health, headquartered in Chicago and a wholly-owned subsidiary of CVS Health since 2023, has agreed to pay $60 million to resolve allegations that it violated the False Claims Act by paying kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street Health’s primary care clinics, according to a news release issued by the U.S. Department of Justice (DOJ). Reporting the lead story during the next live edition of Monitor Mondays will be Max Wollman, a partner in the Washington office of Whistleblower Partners, LLP. The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Joseph Stinson. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Mr. Stinson is expected to receive $9.9 million, according to the DOJ. Other segments during the weekly Internet broadcast will include these instantly recognizable features: •Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. •The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. •Legislative Update: Adam Brenman, senior government analyst for Zelis, will report on current healthcare legislation. •Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays. Pace, in making the statement, was referring to rules and regulations set forth in the Federal Register for Medicare in 2024. She also alleges that some Medicare Advantage (MA) plans are not abiding by some of those rules and regulations. Pace says all MA plans need to abide by the IPO and reimburse correctly. But does your facility have the processes in place to ensure that you are being paid correctly for surgical procedures on the IPO? Be sure to listen in order to find out. Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

What’s wrong with this picture? With more than 10 years of the Centers for Medicare & Medicaid Services (CMS) Two-midnight Rule now behind us, one would presume that most healthcare professionals should know what determines an inpatient status. But some don’t. That is why RACmonitor has invited renowned physician and attorney Dr. John K. Hall to report on the requirements and risks associated with inpatient order documentation during the next edition of Monitor Mondays. Other segments during the weekly Internet broadcast will include these instantly recognizable features: Monday Rounds: The RAC Report: Legislative Update: Risky Business:

A comprehensive new survey featuring responses from more than 1,500 U.S. patients reveals that they are not only frustrated by poor provider support, but also are experiencing tangible health setbacks – especially when waiting to refill prescriptions and being placed on hold while waiting to speak to a caregiver. Israel Krush, CEO and Co-Founder of Hyro, the healthcare vendor whose company sponsored the survey, is scheduled to be the special guest during the next live edition of the long-running Internet broadcast Monitor Mondays, produced by RACmonitor. Hyro’s “Voice of the Patient” survey and accompanying report highlight significant gaps between patient needs and the current support available through healthcare delivery channels. Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

In response to the devastation caused by Hurricane Debby, now Tropical Storm Debby, the Centers for Medicare & Medicaid Services (CMS) has announced additional resources and flexibilities to support the affected states of Florida, Georgia, and South Carolina. Following President Biden’s emergency declarations and U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra’s Public Health Emergency determination, CMS is working closely with these states to ensure continued access to critical healthcare services. Importantly, CMS is offering state waivers and other support to help healthcare providers in the impacted regions maintain operations and deliver essential care during this challenging time, according to Timothy Powell, an independent senior healthcare consultant, who also serves as the national correspondent for ICD10monitor and will be the special guest for the next edition of Monitor Mondays. Other segments during the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The U.S. Department of Justice (DOJ) has a new whistleblower reward initiative called the DOJ Corporate Whistleblower Awards Pilot Program. The Program, which seeks to fill gaps left by existing whistleblower reward programs, incentivizes whistleblowers to bring tips to the DOJ about types of healthcare fraud not already covered by the False Claims Act (FCA). According to Monitor Mondays special guest Mary Inman, the new Program raises the stakes for the entire healthcare industry, especially among those who typically ignore or disregard internal reports concerning whistleblowers. Other segments during the next edition of the weekly Internet broadcast will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Cate Brantley, a senior government affairs liaison for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

The Inpatient Prospective Payment System Final Rule for Acute Care and Long-Term Care hospitals in the 2025 fiscal year (FY) continues to generate interest from providers, payers, hospital administrators, vendors, and consultants. But what are the significant takeaways for stakeholders as they prepare for the government’s fiscal year, which begins Tuesday, Oct. 1, 2024? Standing by to report the lead story during the next live edition of the long-running Monitor Mondays broadcast will be subject-matter expert Dr. James Kennedy. Other broadcast segments will include these instantly recognizable features: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. • Legislative Update: Adam Brenman, a senior government affairs liaison for Zelis, will report on current healthcare legislation. • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.