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Monitor Mondays

Health & Wellness Podcasts

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:

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:


United States


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:






2022: Look Out, Look Ahead

With the calamitous year of 2021 now in the rearview mirror, slowly receding from view, its legacy is expected to have a haunting effect, now and in the future, on America’s system of healthcare. And decisions being made in Washington, D.C. will impact every practice, facility, and health system for months or even years to come. With so many major changes expected to take place in 2022, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front...


The Audit Roundup: Who’s at Risk and Why

The Medicare regulatory audit landscape is rapidly changing, putting providers, vendors, and suppliers at significant risk. And this risk is significantly increased if you’re not aware of the changes. The penalties are severe. The next weekly edition of Monitor Mondays will provide a comprehensive overview of this new forboding landscape and its features. For example, Medicare home health is moving quickly into the world of value-based purchasing. Beginning Jan. 1, 2023, all home health...


You’re an Audit Target: Special Audit Deflection Report

The auditing never stops, and the pace is quickening. New issues, new audits. But what are the costs for hospitals seeking to avoid audits? In one of the most comprehensive reports of its kind ever offered, RACmonitor and Monitor Mondays will bring on board prescient thought leaders to define the contours of this deepening healthcare regulatory crisis. During the next edition of Monitor Mondays, our very own physician-attorney John Hall will report on the Centers for Medicare & Medicaid...


Resisting Medicare Advantage Bullies

"It’s time to stop getting stuck thinking we have a square-peg-and-a-round-hole problem, and focus on the fact that 42 CFR codifies and makes it law that a Medicare Advantage plan, even though it has autonomy in its contract, cannot offer less benefits than Medicare. Medicare Advantage plans cannot have more restrictive guidelines than Medicare; they must at the very least adhere to the simplistic confines of traditional Medicare” – this according to Dr. Jerilyn Morrissey, who will make her...


A Tsunami of Medicare Audits

The signs are ominous. New final rules have been published. All the auditors are there, ready to pounce. Warnings are being sounded. It’s a tsumani of audits. During the next live edition of Monitor Mondays, we’ll report on the latest news and most current updates, offering you our early warning alert system. You’ll receive the latest national audit news updates from well-respected broadcast consultants, including: Special Report: RAC Report: Monday Rounds:Legislative Update: SDoH Report:...


Shooting Fish in a Barrel: More Audits Coming as CMS Releases Flurry of New Rules

Using artificial intelligence (AI), along with an uncanny ability to misinterpret rules, Medicare auditors – specifically, third-party auditors of Medicare Advantage (MA) plans – are ever-ready to pounce on healthcare providers. And too often, it’s like shooting fish in a barrel. The recent posting of three final rules will give auditors ample opportunity to search for more inadvertent errors on Medicare claims. Last week, as reported by RACmonitor, the Centers for Medicare & Medicaid...


Never-Before-Revealed Secrets: How Auditors’ Bias Works Against Providers (Part I)

The next three consecutive Monitor Mondays broadcasts will constitute an explosive series, exposing for the first time how auditors can skew the universe of claims to be audited to their advantage by hiding zero-paid claims. Learn about this outrageous behavior when RACmonitor investigative reporter Edward C. Roche presents the first edition of his three-part series that exposes wrongdoing that is penalizing providers and threatening their financial stability. Monitor Mondays will also...


Open Season on Providers: Beware of the Land Mines

Operating with virtual impunity, while relying on artificial intelligence, payor auditors have locked on to providers to deny claims that trigger audits. Acts of omission by providers are often deemed acts of commission in the eyes of auditors – and the audits often lead to recoupment. Even the slightest apparently innocuous action can trigger a cascade of negative reactions, including denials. Even knowing of misconduct is a major problem. During the next live edition of Monitor Mondays,...


Audit News Roundup: Open Season on Providers

Once suspended by COVID-19, claim audits are now back on the frontburner – Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Medicare Administrative Contractor (MAC) audits, plus Targeted Probe-and-Educate (TPE) audits are the new (or renewed) normal. It’s open season on providers, which is why, in large measure, the next live edition of Monitor Mondays will feature reports on how audits now being conducted by governmental and third-party contractors are...


The Surprising Truth about the No Surprises Act

Big surprise. But not really. The Interim Final Rule (IFR) for the federal No Surprises Act, released last month, appears to offer bad news for out-of-network providers (OON), which does not come as a surprise to heathcare attorney Thomas Force, who will return to the Monitor Mondays broadcast. Force will explain, citing that the guidance is focused on what the bill defines as good-faith estimates for uninsured and self-pay patients, along with the Independent Dispute Resolution (IDR)...


Beware: Inpatient Short Stays in the Crosshairs

The heat is on. As reported by RACmonitor, Livanta, the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) auditor, has started sending out documentation requests for short-stay inpatient audits. For targeted hospitals, Livanta will select 30 inpatient admissions of Medicare beneficiaries whose length of stay (LOS) was either zero or one day within the prior three months. So beware. And be prepared. For context on this development, Dr. John Zelem will report...


Auditors Gone Wild: Rampant Fraud Reported with Medicare Advantage

Rampant auditing by Medicare Advantage (MA) plans is a constant occurrence, with notable cases being reported weekly by RACmonitor. To wit: the recent U.S. Department of Justice (DOJ) filing of a complaint in intervention in a case against Independent Health of Buffalo, New York and its coding vendor, DxID. And there’s the recent case of Sutter Health and its $90 million settlement in a MA risk adjustment fraud case. The DOJ even intervened recently in a consolidation of six whistleblower...


Prepare Now Audit Frenzy Amid Hospitals Executing Crisis Standards of Care

As healthcare attorney Knicole Emanuel recently reported here on RACmonitor, in 2022 providers can expect a “frenzy” of audits – although it seems to be happening already now, as some hospitals are executing crisis standards of care while coping with an influx of COVID-19 patients (namely, unvaccinated patients who have contracted the deadly Delta variant). The result is that many hospitals are on the brink of disaster, their resources stretched to the breaking point. Joining the next...


Clinical Validation Denials: No Longer Uncommon, Definitely Unwelcomed amid Rampant Auditing

Reports of rampant Medicare and Medicaid auditing are pervasive. It seems like every day, hospitals and physician practices are undergoing audits of their medical claims.. These are clinical validation audits, the type of auditing in which the rejections of claims are based on someone’s subjective opinion that certain medical conditions were not present. Reporting on these all-too-common and unwelcomed clinical validation denials will be Erica Remer, MD, a special guest during the next live...


National Healthcare Audit Roundup: Sutter Health Hit with $90 Million FCA Settlement

They take no breaks. Auditors for the government and payers continue to work around the clock, auditing Medicare and Medicaid claims, looking for low-hanging fruit, hoping to ding providers for mistakes made when submitting bills for medical services. Monitor Mondays will have the latest national audit news during the next live edition of the trusted weekly news and information Internet radio broadcast. Featured updates from well-respected Monitor Mondays consultants include the...


National Regulatory and Audit Review: Risk of Audits for E&M Codes

2021 brought a very significant change in how evaluation and management (E&M) visit codes are determined – and with that, concern over how it may impact coding behavior. The big concern: a shift from the lower-level visit codes to the higher-level visit codes: in particular, 99214, 99204, and 99205. The big question: is this shift justified, and does it change the potential for audit risk? Joining the next live edition of Monitor Mondays will be senior healthcare Frank Cohen, who will...


UnitedHealth Under Fire

In a legal decision handed down last week by the Washington, D.C. Circuit Court of Appeals, UnitedHealth and other private payers administering Medicare Advantage (MA) plans were ordered to return overpayments – despite receiving incorrect diagnoses from providers submitting claims. The decision is likely to have serious ramifications, to the tune of tens of billions of dollars. It’s been estimated that such MA overpayments in 2016 soared to more than $16 billion. The bad news is that...


Observation versus Inpatient Divide Heralds Surge in Denials and Audits

The battle lines have been drawn between observation and inpatient status, as hospitals jockey for appropriate reimbursement for comparable patient care. And this standoff is creating an opening for a surge of potential Medicare audits. Auditors — lean and mean from slim audit pickings during the coronavirus pandemic — are hungry, looking for the low-hanging fruit created when administrators, physician advisors, and case managers aren’t on the same page, putting hospitals at even greater...


Spike in Audit Activity Sets Off Alarm Bells: A Regulatory News Update

Medicare and Medicaid auditors are becoming more and more aggressive, threatening the livelihood of providers willing to accept such federally covered beneficiaries. Should there be an act of Congress to pass legislation to address this? How long will aggressive auditing that allows third parties to run roughshod over providers continue? To learn the extent of recent auditing activities, listen to the next live edition of Monitor Mondays, coming your way on Monday, Aug. 9 at 10 a.m....


Audit and Regulatory News Roundup: A New Surge in Post-Pandemic Audits

Like the recent surge of coronavirus infections in many parts of the country, audits are springing up everywhere – with no end in sight. Commercial and government auditors are seizing on any and all perceived errors in medical claims, calling for reviews and other deleterious actions. It’s audit time in Audit Nation. Adding insult to injury is a new ruling handed down by the 5th Circuit Court allowing the U.S. Department of Justice (DOJ) to dismiss a whistleblower’s False Claims Act (FCA)...