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Exclusive: The Plight of Rural Health, Part I

With a 30,000-foot view of rural healthcare policies and regulations emanating from Washington, D.C., Leslie Marsh still recognizes the importance of having boots on the ground, serving as the chief executive of Lexington Regional Health Center in Lincoln, Neb. Marsh, who also serves as vice president of board of directors for the ruralMED Health Network, addresses the ubiquitous Z codes and their impact on the rural population, among other serious issues facing rural healthcare providers,...


Exclusive: The AI Arms Race in Medicare Audits

The artificial intelligence (AI) arms race is heating up. The use of AI by healthcare providers responding to a wave of audits initiated by AI systems is an escalation. As the government continues to deploy AI systems in Medicare audits, providers will respond with their own counter-measures, also using AI. Reporting our lead story during the next edition of Monitor Mondays will be RACmonitor investigative reporter Edward Roche, who continues to monitor the intensifying showdown. Other...


War on Drugs: EHR Vendor Admits to Receiving Illegal Kickbacks from Opioid Pharmas

Practice Function, Inc., a unit of Allscripts Healthcare Solutions Inc., engaged in an "abhorrent" scheme to help a pharmaceutical company push its extended-release opioids, according to a news release posted on Monday by the U.S. Department of Justice. The company agreed to pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software. Practice Fusion admitted soliciting and receiving kickbacks from a major opioid company in exchange...


Balancing Billing: A Swirling Controversy

What once appeared to be a legislative slam dunk is now mired in controversy, this time fueled by the recently formed coalition dead-set against the proposed use benchmark payments. The Coalition Against Rate-Setting considers the practice tantamount to price-fixing. What will happen next to the compromise legislation, which was hammered out with bipartisan congressional support? Matthew Albright, chief legislative affairs officer for Zelis, reports our lead story during this edition of...


War on Drugs: Court Orders AmerisourceBergen to Hand Over Opioid-Related Documents to Pension Fund

AmerisourceBergen, one of the nation’s largest pharmaceutical wholesalers, must turn over records to pension fund shareholders probing to determine wrongdoing by the drug distributor’s board for the company’s multi-billion-dollar legal exposure from the nationwide opioid crisis. AmerisourceBergen was already facing two congressional investigations, plus a Drug Enforcement Administration (DEA) probe. Reporting on this developing story is famed whistleblower attorney Mary Inman, a partner in...


2020: Look Out, Look Ahead

2020 ushers in a formidable decade of healthcare regulations and a perilous audit landscape, populated with aggressive auditors who will be aided by artificial intelligence to review and deny claims. Decisions being made in Washington, D.C. will impact every practice, facility, and health system. With so many major changes taking place, you need to stay informed and alert – and RACmonitor and Monitor Mondays will help you stay out in front of the issues that will alter the delivery of...


Monitor Mondays 10th Anniversary Tribute

Join us for a unique look behind the scenes with long-time Monitor Mondays moderator Clark Anthony as he interviews many of our esteemed panelists from the last 10 years.


Home Health and Hospice: State of the Union

It’s been a rough year for home health and hospice providers, especially in light of the fact that the Centers for Medicare & Medicaid Services (CMS) included a reduction in the base payment rate of 8.01 percent in the Patient-Driven Groupings Model (PDGM) of the 2020 Home Health Prospective Payment System Rate Update. Returning to Monitor Mondays is William Dombi, president of the National Association for Home Care and Hospice, who will provide a regulatory update for his association as...


Rural Health: State of the Union

Rural hospitals are an endangered species in America, with extinction a real possibility. In fact, the North Carolina Rural Health Research and Policy Analysis Center report that more than 120 hospitals have closed nationwide since 2005, with nearly 70 percent (or 83) of those closures occurring since 2010. Adding insult to injury is the recent announcement from the Centers for Medicare & Medicaid Services (CMS) that Monday, Dec. 2 is the deadline for critical access hospitals (CAHs) to...


Discharge Planning Conditions of Participation: The IMPACT and Consequences

Many hospitals are likely in the throes of preparing to implement the Centers for Medicare & Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, including how to reconcile the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The new rule becomes effective Friday, Nov. 29, 2019. “CMS has spent the last two years working on the IMPACT Act, and they are now ready to implement,” reports Mary Beth Pace, vice president of care management at...


Monitoring Patient Mortality: Compliance and Quality

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 Monitor Mondays is Melinda Battaile, MD, physician advisor and clinical...


Known by the Company You Keep: Disclosures of Affiliations

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. Reporting our lead story during this edition of Monitor Mondays is healthcare...


Anatomy of an Algorithm: Optum Algorithm Under Fire for Alleged Racial Bias

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 was, indeed, Optum. Reporting on this developing story during this edition of...


CMS Site-Neutral Payments: Hospitals Win, CMS Loses, but the War is Not Over

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 hospitals, but the war is far from over. Reporting on this developing story...


Feds Putting the Squeeze on Medicare and Medicaid Payments: $252.6 Billion in Cuts Reported

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 official Matthew Albright, chief legislative affairs officer for Zelis...


PDPM: New Reimbursement Model is Driving Disruption

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 Center for Medicare Advocacy. The new PDPM system reverses the financial...


340B Drug Program in CMS Crosshairs

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 which a federal judge ruled against the move. Reporting our lead story during...


Developing Story: Virginia Governor and MCOs Sued by Behavioral Health Providers

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 Mondays, healthcare attorney Knicole Emanuel, a partner in the aforementioned law...


Developing Story: Virginia’s Behavioral Health Providers Under Siege

Other segments to appear during the live broadcast include the following: RAC Report: SDoH Report: Monday Focus Risky Business: Monday Rounds:


No Time for SNFs: PDPM Becomes Effective Oct. 1

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) audit. Reporting our lead story during this edition of...