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Episodes

The Dilemma of Sepsis Reporting

12/10/2018
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Controversy swirls and denials of claims continue when it comes to reporting sepsis. Exacerbating this compliance issue is the dual definition of the condition: The Centers for Medicare & Medicaid Services (CMS) and in many cases, payers use the Sepsis 2 definition, while generally, providers rely on Sepsis 3. Joining us on this episode of Monitor Mondays, Mary Beth Pace, vice president of care management at Trinity Health, will share how her system approaches the dilemma of sepsis. The...

Duration:00:31:05

Dismissal Expected in Providence Health FCA Lawsuit

12/3/2018
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During this edition of Monitor Mondays, nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reports on the expected dismissal of the $188.1 million False Claims Act lawsuit filed by Med Analytics, LLC against Providence Health, now Providence St. Joseph, for allegedly upcoding various diagnoses. According to news reports, the United States declined to intervene in the case, and the allegations are likely to be dropped on Jan. 14,...

Duration:00:28:27

Medicare Advantage Claim Denials: More Egregious, or More Awareness?

11/26/2018
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Are recent denials by Medicare Advantage plans egregious examples of the insurance companies’ overreach? Or is there simply greater awareness of an age-old problem? Sorting out this ongoing issue during this edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare in Greenwood, N.C. and a member of the board of directors of the American College of Physician Advisors. Dr. Baker has been working with the Centers for Medicare &...

Duration:00:30:43

Court Orders HHS to Clear Medicare Appeals Backlog

11/12/2018
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U.S. District Court Judge James E. Boasberg ruled last week that the U.S. Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog by the end of fiscal year 2022. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. In other news, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Medicare Home Health final rule. Reporting on this major...

Duration:00:30:31

2019 MPFS and OPPS Final Rules: Where Are We Today

11/5/2018
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Long awaited and hotly debated, the 2019 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS) final rules have been on the minds of healthcare shareholders since late July, when the Centers for Medicare & Medicaid Services (CMS) released proposed rules for both. Tucked into the MPFS were the controversial revisions to the regulations governing evaluation and management (E&M) services. For an in-depth analysis of both the MPFS and the OPPS newly released...

Duration:00:30:14

Provider-Based Clinics: Major Changes Coming Soon

10/29/2018
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The Centers for Medicare & Medicaid Services (CMS) is expected to release its final rule concerning provider-based clinics early in November. The proposed changes are expected to impact compliance and reimbursement. Reporting this developing story during this edition of Monitor Mondays is author, educator, and consultant Duane Abbey, who will discuss how the proposed changes are likely to impact Medicare providers. The broadcast rundown also will include: False Claims Act: Risky...

Duration:00:30:58

CMS Proposes Changes to Medicare Shared Savings Program: Probing the Impact on Providers

10/22/2018
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The Centers for Medicare & Medicaid Services (CMS) has released its proposed changes to the Medicare Shared Savings program. Reporting this developing story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, who will discuss how the proposed changes are likely to impact Medicare providers. The broadcast rundown also will include: TPE: Death by Cyber, Part II: Risky Business: Hot Topics: Monday Rounds:

Duration:00:30:24

Targeted Probe-and-Educate Audits: Three Strikes and You’re Out

10/15/2018
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Targeted probe-and-educate (TPE) reviews by the Medicare Administrative Contractors (MACs) give providers and suppliers three changes to get it right or they’re out. If there are continued high denials after the first three rounds of reviews, the provider is referred to the Centers for Medicare & Medicaid Services (CMS) to determine additional disciplinary action – either extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC),...

Duration:00:30:43

UnitedHealthcare Puts Sepsis in the Crosshairs

10/8/2018
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UnitedHealthcare (UHC) is putting providers on notice: Come Jan. 1, 2019, the industry giant will use the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated, advising that the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score is to be used to determine if sepsis is present. If reviewers find no SOFA score in the medical record, that could spell trouble – audit trouble. Reporting on this topic during this edition of Monitor Mondays is Edward Hu,...

Duration:00:31:10

CMS Proposes to Implement Home Health Pre-Claim Review Demonstration

10/1/2018
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Home health providers are now on alert following an announcement on Wednesday that the Centers for Medicare and Medicaid Services (CMS) intends to implement in December its Home Health Pre-Claim Review demonstration in Illinois, Ohio, North Carolina, Florida, and Texas. In its announcement, CMS issued a notice for a 30-day public comment period. Reporting this developing story during this edition of Monitor Mondays will be William A. Dombi, president of the National Association for Home...

Duration:00:32:44

CMS Proposed Rule Intended to Alleviate Regulatory Burdens: Will it Work?

9/24/2018
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As expected, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an attempt to alleviate regulatory burdens on certain Medicare providers. The proposal will revise 42 CFR Parts 403, 416, 418, 441, 460, 482-86, 488, 491, and 494. Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, partner in the Potomac Law Group. The broadcast rundown also will include: Monday Focus: Monday Rounds: Hot Topics: Risky...

Duration:00:29:45

Compliance During Adversity: Hurricane Florence

9/17/2018
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As bands of rain and wind from Hurricane Florence are lashing North Carolina, hospitals, health systems, and physician practices are preparing for what is being called the “storm of a lifetime.” Earlier this week, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar declared public health emergencies in North and South Carolina. Such a designation makes it easier to ensure that Medicaid and Medicare beneficiaries have access to medical care despite the storm, according to a...

Duration:00:30:54

Last Chance to Take a Stand: Comment Period for Proposed E&M Changes Ends

9/10/2018
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Few proposals from the Centers for Medicare and Medicaid Services (CMS) have generated such a plethora of opposition from concerned stakeholders as the agency’s recent proposed evaluation and management (E and M) reimbursement changes in the 2019 Medicare Physician Fee Schedule. The outrage has been intense over the plan to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to...

Duration:00:30:28

Anatomy of an Alleged False Claims Act Violation: The Providence Health & Services Lawsuit

8/27/2018
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A False Claims Act lawsuit has been filed by Integra Med Analytics against Providence St. Joseph Health, seeking $188.1 million related to alleged upcoding of Medicare claims. According to media reports, Integra made the discovery of allegedly unwarranted major complication and comorbidity secondary codes. In its investigation, Integra identified J.A. Thomas and Associates (JATA) as the clinical documentation improvement consultancy for Providence. The lawsuit alleges Providence and JATA...

Duration:00:30:04

CMS, Are You Listening? Podiatrists React Negatively to Proposed E&M Changes

8/20/2018
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“Podiatrists should not be discriminated against any further. E&M (evaluation and management) requirements are the same as (those for) other providers, and we should be reimbursed justly,” one podiatrist recently wrote, expressing his opposition to the Centers for Medicare & Medicaid Services’ (CMS’s) proposed E&M reimbursement changes in the recently posted 2019 Medicare Physician Fee Schedule. “If Medicare is going to change E&Ms to only two codes, then all specialists should be changed,”...

Duration:00:30:24

Controversy Continues to Swirl Around Proposed E&M Changes

8/13/2018
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The Centers for Medicare & Medicaid Services’ (CMS’s) proposed evaluation and management (E&M) code changes in the recently posted 2019 Medicare Physician Fee Schedule continue to generate controversy. The controversy centers around the proposal by CMS to reimburse new patient visits at a single flat rate for codes 99202-99205 (99201 would be paid at a lower rate), while a corresponding, lower flat rate would apply to established patient visit codes 99212-99215. Code 99211 would also be paid...

Duration:00:30:27

2019 Medicare Physician Fee Schedule and the Outpatient Prospective Payment System: Analyzing the Impacts on Providers

8/6/2018
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The Medicare Physician Fee Schedule/resource-based relative value scale (MPFS/RBRVS) regulations were formally published in the Federal Register on July 27, 2018. The Outpatient Prospective Payment System/Ambulatory Payment Classifications (OPPS/APCs) was released two days prior. Both were reported by RACmonitor. Although you can expect the final changes to published in early November, for a contemporary analysis listen to Duane Abbey during this edition of Monitor Mondays. Duane Abbey is...

Duration:00:30:04

Beware: Emerging New Payer Denial for COPD

7/30/2018
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There’s a new and disturbing payer denial—a situation that has caught the attention of the Brundage Group. An insurance company removed the diagnosis of COPD exacerbation because the treating physician chose not to treat using steroids. Could this denial be happening at your facility? Dr. Brett Hoggard, chief medical officer for the Brundage Group, reports on this new and disheartening denial technique. The broadcast rundown also will include: The RAC Report: Hot Topics: Risky Business:...

Duration:00:29:36

Court Ruling Creates Major Setback for 340B Drug Program

7/23/2018
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The 340B drug pricing program suffered a major setback Tuesday, when the U.S. Court of Appeals dismissed a key American Hospital Association (AHA) lawsuit to block $1.6 billion in cuts. The three-judge panel ruled that the lower court had properly dismissed AHA's case because the association failed to fulfill the legal prerequisites to judicial review. Reporting our lead story during this edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner at the Potomac Law...

Duration:00:30:41

Case Management in the ED: Getting Patient Status Right the First Time

7/16/2018
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Case managers being situated in the emergency department (ED) appears to be a trend that is gaining traction nationwide, as results indicate that such a move helps determine appropriate status while also identifying patients who are appropriate for placement into a skilled nursing facility (SNF) directly (instead of placing them into the hospital while searching for a facility). We have two reports on this trending topic during this edition of Monitor Mondays. Leading our report is Juliet...

Duration:00:31:08