Podcasts about Medical necessity

It was 3 o'clock in the morning when Scott Middleton finally signed the papers. The merger was official. And within days, he was already on the road — visiting facilities, riding along with providers, and spotting the same gap everywhere he went: brilliant clinicians doing real work that was completely invisible to the system. In this episode of The Disrupted Podcast, Jamie sits down with Scott Middleton, calling in from Boston, to unpack what he's discovering on the ground in the newly merged Your Health organization — and why tracking your time isn't about paperwork. It's about protection, proof, and getting paid for every minute of care you're already delivering. What you'll hear in this episode: The Dr. Jeeve story: a high-producing doc who managed a nursing home crisis by phone, saved a patient from an unnecessary ER visit — and never billed for it, leaving Medicare with no record of his intervention Why not documenting a visit before a hospitalization doesn't just cost you revenue — it makes you look like a bad provider, even when you did everything right How insurance companies like United Healthcare boldly take 15% off the top of every healthcare dollar — and why that math means providers can't afford to give their time away for free The TCPA pattern Scott keeps seeing: 15,000–18,000 visits a month, almost entirely in nursing homes, with zero follow-up once patients go home The new post-discharge standard: every patient leaving a nursing home gets a telehealth visit within 48 hours, then weekly follow-up for four weeks — no one gets left in the gap This episode is a masterclass in understanding that documentation isn't bureaucracy — it's how you tell your story, protect your reputation, and keep the care you've already given from disappearing. www.YourHealth.Org

SummaryIn this episode of The Compliance Guy, Sean Weiss and Terry Fletcher discuss various compliance issues related to audits, medical necessity, and the importance of thorough documentation in healthcare. They engage in a role play to illustrate common pitfalls in audits, emphasizing the need for physicians to conduct appropriate examinations and maintain accurate records. The conversation also touches on the impact of electronic medical records (EMR) and artificial intelligence (AI) on healthcare practices, highlighting the risks of relying on outdated or incorrect information. The episode concludes with a call for healthcare providers to take responsibility for their documentation and patient care.TakeawaysAudits often reveal common sense oversights in healthcare practices.Physicians must understand the difference between hospital-based and private practice standards.Medical necessity is crucial for justifying patient evaluations and management services.Technicalities in documentation should not overshadow clinical responsibilities.Inaccurate or outdated information in EMRs can lead to significant risks in patient care.Providers should not rely on loopholes in guidelines to justify their actions.The importance of a medically appropriate history and examination cannot be overstated.Documentation should reflect current patient status, not historical data.AI and EMR systems can exacerbate existing documentation issues if not managed properly.Healthcare providers must prioritize accuracy and thoroughness in patient evaluations.

This week on the podcast I have Chelsea and Bilal sharing the birth story of their second child. A planned homebirth took an unexpected turn, in that it needed to proceed in the hospital. Adjusting our minds from our ideal birth, to that which unfolds - is every person's challenge. Giving birth is the ultimate lesson in surrender, and Chelsea and Bilal demonstrate this beautifully through their story. They are both an inspiration - enjoy! Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Today I experienced the joy of talking with Daniella about her homebirth. She came into the birth process feeling confident in her ability to give birth, and she prepared using the Transform Your Birth course. This really got her partner on board and he became an integral part of the birth logistics. Daniella exudes confidence in her ability to give birth and she surrendered completely into labourland. The interesting thing about her story is that her contractions never showed signs of being 3 minutes apart regularly, and she caught her midwives off guard. I loved hearing about her meeting with her daughter. It was a divine moment. A lovely - confidence building story - enjoy dear ones. Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Lindsey Nelson, Product Marketing Leader at Infinx, explains how Infinx is bringing Medical Necessity AI Agent to market through a phased launch shaped by research, beta feedback, and early customer evaluation. She also outlines what makes the solution different from rules-based tools, including explainable clinical reasoning that helps teams assess coverage earlier and prevent denials before submission.

This week I had a beautiful conversation with the whole family including little 4 month old Liam. Bek and Tim share the experience of having a very quick birth, with strong contractions right from the beginning. They had to trust their own judgement about the need to go to the hospital, when Bek started to feel the urge to push at home. Bek knew what positions she needed to be in, and experienced great support from Tim, her doula and hospital midwives. We also go into the uniqueness of the bonding experience from both perspectives. A rich conversation - enjoy dear ones! Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Send us Fan Mail(Part 2 of 2) Grab a seat and pour yourself a cold one! In this episode, Mike and Dan are cracking open the white paper from Optum, titled "Low Hours, High Impact".For years, the "more is better" 40-hour-a-week model has been the industry standard, but the data is starting to tell a different story. We're diving deep into the science and the shift toward Value-Based Care, exploring how focused, high-quality interventions can sometimes move the needle further than pure volume.In this "pour," we're serving up:The 40-Hour Hangover: Why the "intensive" model might not always be the most effective for every learner, especially the little ones.Efficiency on Tap: Breaking down Optum's findings on how lower-intensity, high-precision services can drive meaningful clinical outcomes.The Payer's Perspective: A look at how major payers like Optum are redefining "Medical Necessity" and what that means for your clinic's billing and documentation in 2026.Quality over Quantity: How to advocate for the right amount of hours without sacrificing progress or burning out your RBTs.Whether you're a BCBA navigating authorization battles or a business owner looking at the future of ABA funding, this episode delivers the straight talk you need—minus the boring jargon.Tune in, drink up, and always analyze responsibly. Support the show

Medical necessity review is getting harder as payer policies change more often and AI allows health plans to evaluate cases at greater speed and scale. In this episode, Navaneeth Nair explains why older rules-based tools could not fully solve the problem and how a new AI approach can help providers assess unstructured documentation, preserve scarce expertise, and prevent denials earlier in the revenue cycle.

Send us Fan Mail(Part 1 of 2) Grab a seat and pour yourself a cold one! In this episode, Mike and Dan are cracking open the white paper from Optum, titled "Low Hours, High Impact".For years, the "more is better" 40-hour-a-week model has been the industry standard, but the data is starting to tell a different story. We're diving deep into the science and the shift toward Value-Based Care, exploring how focused, high-quality interventions can sometimes move the needle further than pure volume.In this "pour," we're serving up:The 40-Hour Hangover: Why the "intensive" model might not always be the most effective for every learner, especially the little ones.Efficiency on Tap: Breaking down Optum's findings on how lower-intensity, high-precision services can drive meaningful clinical outcomes.The Payer's Perspective: A look at how major payers like Optum are redefining "Medical Necessity" and what that means for your clinic's billing and documentation in 2026.Quality over Quantity: How to advocate for the right amount of hours without sacrificing progress or burning out your RBTs.Whether you're a BCBA navigating authorization battles or a business owner looking at the future of ABA funding, this episode delivers the straight talk you need—minus the boring jargon.Tune in, drink up, and always analyze responsibly. Support the show

SummaryIn this episode, healthcare attorney and expert Dean Viskovich discusses the complexities of telehealth, medical necessity, and laboratory compliance, providing practical guidance for labs and billing companies navigating CMS and payer requirements.Key TopicsMedical necessity and legal standardsImpact of recent court decisions on labsBest practices for compliance and documentationHere is a link to Dean's Website: https://deanviskovichpa.com/team/dean-m-viskovich/

SummaryThis episode features a comprehensive discussion on current issues in healthcare compliance, including RadV audits, auto down coding, medical necessity, and the impact of AI in billing practices. Experts share insights on regulatory challenges, provider strategies, and the future of healthcare billing integrityTopicsRadV audits and their impact on providersAuto down coding and its implicationsMedical necessity standards in Medicare and commercial payersThe role of AI in billing and coding accuracyLegal and contractual considerations in healthcare billing

Discover how FSA funds can unlock savings on home gym equipment. Experts explore the Letter of Medical Necessity, modern health platform partnerships, and how pre-tax dollars are making fitness more accessible than ever.Info: https://www.soletreadmills.com/pages/truemed-shop-with-hsa-fsa-funds SOLE Fitness City: Salt Lake City Address: 56 Exchange Pl. Website: https://www.soletreadmills.com/

 It was a total joy to talk with Andrew in this episode years after the birth of his two sons. He shares how their first birth caused them to make very different decisions for the second birth. We discuss the challenges of different advice, not feeling heard or respected, and the role of the father, or partner. What I loved the most about our conversation was connecting the dots between birth, and life afterwards. Andrew and Kate have taken these experiences and used them to forge strong family bonds that can last a lifetime. Such wisdom from this devoted dad. Enjoy! Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Broadcasting live from Infinx's GTM Growth Summit in Denver, Navaneeth Nair, Chief Product Officer, joins Office Hours to discuss a new AI-driven approach to medical necessity review. We'll explore how provider teams can catch coverage gaps earlier, reduce manual policy lookups, and route exception cases to the right human experts before delays and denials take hold. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

 I have the pleasure today of presenting a dear mother - Priyanka. Pri shares her experiences of 2 caesareans and the importance of being an advocate for yourself. She shares that on the day, you are the centre of the universe and should not be worried about the people around you. At the end we discuss the power of having a post natal doula, which completely changed her experience of those tender weeks afterwards. An episode from a truly wise woman, who can see the power of her birth experiences years down the track. Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Writer Róisín Michaux investigates women's rights and free speech in the context of the transgender movement. Róisín brings a uniquely European lens to her research, exposing how LGBTIQ activist organizations in Europe are heavily state-funded — unlike the U.S., where private foundations like the Rockefellers and Ford Foundation dominate — and how this funding pipeline has turbocharged some of the most extreme gender ideology we're seeing today.We dig deep into intersex activism: what it actually is, who's behind it, and why it matters for parents navigating the gender craze with their children. Róisín explains the crucial distinction between people with genuine disorders of sexual development (DSDs) — rare, named medical conditions like congenital adrenal hyperplasia (CAH), Turner syndrome, and complete androgen insensitivity syndrome (CAIS) — and the largely queer-theory-driven "intersex identity" movement that has very little to do with medicine and everything to do with dismantling the sex binary.We also explore the history of brain sex research, how trans activists strategically abandoned the science when it stopped serving them, and how self-ID legislation spread from Argentina to across Europe through incremental legal maneuvers. I close with an important note for parents: understanding the politics of intersex activism is valuable, but knowing how to actually talk to your child about these issues is a different skill altogether — one I teach in ROGD Repair.Róisín Michaux is an Irish writer based in Brussels, Belgium. She writes about women's rights and free speech in the context of the transgender movement. She is specifically interested in LGBTIQ activism, activists' relationship to EU/European bureaucracies, the funding they receive, and how it has all led to deep and anti-democratic policy capture. She has 2 kids and a cocker spaniel. Follow her on X @RoisinMichaux or on Substack at Peaked.[00:00:00] Start[00:02:00] What Is Intersex Activism and Why It Matters[00:07:00] DSDs vs. Intersex Identity: Two Separate Worlds[00:16:00] The Top Line Demand: Stop All Infant Surgeries[00:17:00] Origins of Intersex Activism and John Money's Legacy[00:28:00] Activists vs. Doctors: The Surgery Moratorium Debate[00:36:00] The Real Agenda: Queering the Sex Binary[00:47:00] The Brain Sex Hypothesis and Why Activists Abandoned It[00:54:00] The 1993 Amsterdam Meeting and the Pivot to Self-ID[01:01:00] How Self-ID Laws Crept Through European Courts[01:08:00] Government Funding and How Fringe Ideology Goes Mainstream[01:16:00] Creating Iatrogenic Intersex with Cross-Sex Hormones[01:19:00] DSD Families, the UK Supreme Court, and CAIS[01:24:00] The "Consent at 12" Framework and the Trans Agenda[01:29:00] Medical Necessity vs. Trans Activist Demands[01:36:00] Infighting, Identity, and the Mess of Merging Medicine with Politics[01:39:00] PCOS, Testosterone, and a Word for ParentsROGD REPAIR Course + Community gives concerned parents instant access to over 120 lessons providing the psychological insights and communication tools you need to get through to your kid. Now featuring 24/7 personalized AI support implementing the tools with RepairBot! Use code SOMETHERAPIST2026 to take 50% off your first month.PODCOURSES: use code SOMETHERAPIST at LisaMustard.com/PodCoursesTALK TO ME: book a meeting.PRODUCTION: Looking for your own podcast producer? Visit PodsByNick.com and mention my podcast for 20% off your initial services.SUPPORT THE SHOW: subscribe, like, comment, & share or donate.Watch NO WAY BACK: The Reality of Gender-Affirming Care. Use code SOMETHERAPIST to take 20% off your order.MUSIC: Thanks to Joey Pecoraro for our song, “Half Awake,” used with gratitude & permission. ALL OTHER LINKS HERE. To support this show, please leave a rating & review on Apple, Spotify, or wherever you get your podcasts. Subscribe, like, comment & share via my YouTube channel. Or recommend this to a friend!Learn more about Do No Harm.Take $200 off your EightSleep Pod Pro Cover with code SOMETHERAPIST at EightSleep.com.Take 20% off all superfood beverages with code SOMETHERAPIST at Organifi.Check out my shop for book recommendations + wellness products.Show notes & transcript provided with the help of SwellAI.Special thanks to Joey Pecoraro for our theme song, “Half Awake,” used with gratitude and permission.Watch NO WAY BACK: The Reality of Gender-Affirming Care (our medical ethics documentary, formerly known as Affirmation Generation). Stream the film or purchase a DVD. Use code SOMETHERAPIST to take 20% off your order. Follow us on X @2022affirmation or Instagram at @affirmationgeneration.Have a question for me? Looking to go deeper and discuss these ideas with other listeners? Join my Locals community! Members get to ask questions I will respond to in exclusive, members-only livestreams, post questions for upcoming guests to answer, plus other perks TBD. ★ Support this podcast on Patreon ★

Determining whether documentation truly supports coverage is one of the most complex and costly challenges in revenue cycle today. In this episode, Navaneeth Nair and Yagna Velu discuss the early vision for using AI to strengthen medical necessity review, reduce avoidable denials, and improve decision-making before claims move forward.

This episode was recorded live from Infinx's GTM Growth Summit in Denver. Navaneeth Nair, Chief Product Officer, joins us to discuss a new AI-driven approach to medical necessity review. We'll explore how provider teams can catch coverage gaps earlier, reduce manual policy lookups, and route exception cases to the right human experts before delays and denials take hold.Brought to you by www.infinx.com

Learn how fitness equipment like treadmills is now HSA and FSA eligible, potentially saving you thirty percent through pre-tax dollars. Hear about Letters of Medical Necessity, the difference between HSA and FSA accounts, and how this wellness trend is reshaping preventive healthcare.Info: https://www.soletreadmills.com/pages/truemed-shop-with-hsa-fsa-funds SOLE Fitness City: Salt Lake City Address: 56 Exchange Pl. Website: https://www.soletreadmills.com/

I have a story this week about a vaginal breech birth, which is a  baby born bottom first, rather than head first. Parris shares so much wisdom about preparing for birth, being able to adjust to different paths and creating the right conditions for birth. We discuss how she had to balance her vision of a physiological birth, plus the reality, as she ends up birthing in a different city, with a different team of health professionals. What unfolds is a truly magical path for Parris, as she embraces each lesson and allows herself to be humbled by this inherently significant life event.  This truly is a 'must listen,' episode as we delve into the deeper path that women must walk when facing the mystery of what lies ahead.   Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

I am so very proud to offer you my conversation with Tess today, for the raw truth of what the path to having a baby can deliver. Tess experienced a lot of practice dealing with contractions prior to labour day for weeks leading up to the birth. On birthing day, things progressed very quickly, leading her to birth her first baby within 4 and a half hours. When meeting her baby, she didn't experience the 'rush of love,' people often describe. This led us into a rich conversation about the expectations we carry that we need to 'feel the love,' when a baby emerges. The truth is some people take days, weeks, even months to realise that they love their baby.  Conversations like this help us move beyond ideals and expectations into being ok with whatever unfolds and appreciating that everyone's experience will be different. The moment a baby arrives does not define the relationship over a lifetime. Bonding is a lifelong process. Rich wisdom indeed. Enjoy dear ones.   Links: Transform Parenting website Transform Your Birth Today Better Birth: Mini Gift Free resource: Medical Necessity vs Choice

Medical necessity sits at the intersection of clinical judgment, coverage policy, and payer scrutiny, and on this episode Stuart Newsome, VP of RCM Insights, unpacks what it really means. Joined by Viveka Jagadeesan (Enablement Manager), Lindsey Nelson (Director of Product Marketing), Christina Harkins (Senior Revenue Cycle Manager), and Angie Adams (VP Clinical & Patient Engagement), the group explores Medicare error data, CERT audits, recoupment risk, NCD vs. LCD nuances, and how AI-driven policy intelligence can support medical necessity on both the front and back end of the revenue cycle. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

The ultimate challenge of operating an OBL is staying profitable. In this episode of BackTable, we bring on healthcare administrator Laurie Bouzarelos and interventional radiologist Dr. Mary Costantino to talk through the intricacies of revenue cycle management as an IR managing an OBL. --- SYNPOSIS The conversation covers the full lifecycle of getting paid in an IR practice, from initial patient contact through final claim resolution. Key topics include credentialing, determining medical necessity, coordination of benefits, prior authorizations, and the importance of working with billing and practice management teams experienced in interventional radiology. The episode also examines how EHR and practice management platform selection impacts clinical workflows and reimbursement, and closes with a discussion on payment plans and how emerging technologies, including AI, may shape the future of revenue management in IR-led OBLs. --- TIMESTAMPS 00:00 - Introduction 01:08 - The Importance of Revenue Cycle Management09:29 - The No Surprises Act and Data Transparency12:03 - Professional Societies and Continuing Education17:50 - Credentialing and Taxonomy Codes40:28 - Impact of Insurance Credentialing on Patient Care42:08 - Revenue Cycle Management Walkthrough48:18 - Challenges with Medicare Advantage and Coordination of Benefits54:20 - Covered vs. Non-Covered Services59:03 - Medical Necessity and Insurance Policies01:01:04 - Prior Authorization and Payment Issues01:13:11 - Payment Plans and Compliance01:23:10 - Practice Management Software01:31:10 - AI in Healthcare and Compliance01:38:57 - Final Thoughts --- RESOURCES Medical Group Management Administration (MGMA)https://www.mgma.com/

Medical necessity sits at the intersection of clinical judgment, coverage policy, and payer scrutiny, and in this episode Stuart Newsome, VP of RCM Insights, unpacks what it really means. Joined by Viveka Jagadeesan (Enablement Manager), Lindsey Nelson (Director of Product Marketing), Christina Harkins (Senior Revenue Cycle Manager), and Angie Adams (VP Clinical & Patient Engagement), the group explores Medicare error data, CERT audits, recoupment risk, NCD vs. LCD nuances, and how AI-driven policy intelligence can support medical necessity on both the front and back end of the revenue cycle.

Medical Necessity or Personal Growth? Why Documentation Matters in Therapy Curt and Katie talk about medical necessity in therapy documentation – what it is, why it matters, and how therapists can navigate the tension between clinical care, insurance requirements, and personal growth. We explore how documentation protects therapists in utilization reviews and disciplinary processes, and how to ethically distinguish therapy from coaching or self-improvement. Key Takeaways for Therapists Why documenting medical necessity matters for insurance, ethics, and liability Risks of over-diagnosing or misrepresenting symptoms The role of treatment plans and progress notes in demonstrating medical necessity Navigating personal growth requests vs. clinical therapy Protecting yourself with clear, consistent documentation About Our Hosts Curt Widhalm, LMFT – www.curtwidhalm.com Katie Vernoy, LMFT – www.katievernoy.com Find the transcript and additional resources at mtsgpodcast.com. Join the Modern Therapist Community Linktree Modern Therapist's Survival Guide Creative Credits Voice Over by DW McCann Music by Crystal Grooms Mangano

Recently, a federal court vacated the Centers for Medicare & Medicaid Services 2023 Risk Adjustment Data Validation (RADV) Final Rule.This action is reshaping the landscape for Medicare Advantage compliance. The rule had authorized contract-level extrapolation and eliminated the longstanding fee-for-service (FFS) adjuster — two changes that dramatically increased the potential scale of overpayment recoveries.Reporting this developing story during the next live edition of Monitor Monday will be senior healthcare analyst Frank Cohen,The weekly broadcast 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: Adam Brenman, senior legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO).Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government's fraud detection radar.More on this topic will be reported during the next live edition of Monitor Mondays. That's when whistleblower attorney Max Voldman returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.The weekly broadcast 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 legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Healthcare compliance just shifted fundamentally.Traditional whistleblowers who needed inside access are being replaced by artificial intelligence (AI)-powered relators who mine public datasets and flag statistical anomalies that could signal fraud.The U.S. Department of Justice (DOJ) logged 979 qui tam cases in 2024, many of which were reportedly triggered by mathematical outliers, rather than insider tips. Government agencies, such as the Centers for Medicare & Medicaid Services (CMS), have already recovered $820 million using algorithmic detection.During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will reveal a possible solution for hospitals, health systems, and physician practices.The weekly broadcast 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: Adam Brenman, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Consider this a wake-up call.As artificial intelligence (AI) quietly becomes part of the audit trail, healthcare leaders must ask a new question: who's reviewing the reviewers?During the next live edition of the venerable Monitor Mondays broadcast, contributing editor Sharon Easterling will break down why auditing AI tools are no longer a tech issue – they're a documentation integrity and compliance priority.Although this is an important topic for all healthcare professionals, register now to learn why it's particularly relevant for those in compliance and revenue integrity.The weekly broadcast 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 analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The Unified Program Integrity Contractors (UPICs) are household names in healthcare compliance.But their track record tells a troubling story, according to senior healthcare analyst Frank Cohen. These Medicare fraud enforcement contractors are using controversial extrapolation techniques that providers successfully challenge over 60 percent of the time on appeal.Cohen, who will be the special guest during the next live edition of Monitor Mondays, said he will examine how the 2016 consolidation created five regional enforcement powerhouses, along with why their statistical methodologies are devastating practices based on flawed assumptions. Cohen intends to show how misaligned incentives are creating systematic accuracy problems, while revealing why the current UPIC system might be fundamentally broken, despite everyone agreeing that fraud prevention matters.The weekly broadcast 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: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

There just might be a reign of terror being experienced at many of America's hospitals and health systems. Professionally delivered patient care apparently seems to be getting hijacked by auditors compelled to deny claims of omission.Aided by the Centers for Medicare & Medicaid Services (CMS) and abated by auditors private and public, the lingua franca appears be an entanglement of descriptors, namely “inpatient versus outpatient.”During the next live edition of the venerated Monitor Monday broadcast, several of the most recognized names in healthcare will not add to the confusion, but offer advice for those on the front lines of battle.The weekly broadcast 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 healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Although the lawsuit was filed by a pharmacist in New Mexico, a federal judge in New York has ordered CVS Omnicare to pay $949,000 to settle a False Claims Act (FCA) case.According to news sources, the Pharmacy Benefits Manager (PBM) allegedly prescribed drugs to individuals in long-term residential facilities that were not supported by valid prescriptions and then submitted claims for reimbursement for those prescriptions to Medicare, Medicaid, and TRICARE. Although a jury trial was held last spring, with the judge rejecting post-trial arguments by Omnicare, it is understood that Omnicare plans to appeal.Reporting details of this whistleblower lawsuit during the next edition of Monitor Mondays will be Max Voldman, a partner at Whistleblowers Law, LLP.The weekly broadcast 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: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Federal legislation has been introduced that is intended to help the beleaguered 340B Health organization via an effort to ban pharmaceutical companies from restricting access to the drug pricing discount program of the same name, through community and specialty contract pharmacies.Reporting this lead story as well as other updates from Congress and the Trump Administration during the next live edition of Monitor Mondays will be Maureen Testoni, CEO for 340B Health and a frequent guest on the long-running broadcast. Testoni represents more than 1,600 hospitals and health systems participating in the 340B drug pricing program.The weekly broadcast 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 healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The rugged audit landscape has changed – and not for the better.Today, there are more potential pitfalls and traps to capture the unprepared and impact them with huge fines and possible incarceration. In fact, the Centers for Medicare & Medicaid Services (CMS) has erected a legal fortress to protect their audit process. It's not the same old ballgame – it's a new one, with lots of new players.It's also why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to return to the broadcast to describe how you and your team can learn how to identify red flags in the process of fraud detection in order to avoid liability.The weekly broadcast 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: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

In this powerful episode, Dr. Becky sits down with Pulitzer Prize–winning New York Times science reporter Matt Richtel to explore the urgent mental health crisis facing today's teens—and the science behind what's really going on in the adolescent brain.Expanding on his acclaimed reporting, Matt shares insights from his groundbreaking new book How We Grow Up, diving deep into the neurological, biological, and social transformations that define adolescence.This episode is brought you by Chomps. When it comes to school snacks, I've never been the “pack my kid a portable charcuterie board” kind of parent. If you are, more power to you. I'm more of a “grab-and-go” type - I want something simple, nutritious, and easy for my kids to reach for as we're heading out the door.That's why I like Chomps. Their full-size meat sticks have 10 grams of protein and zero sugar. They're filling and made from real ingredients, so it's one less thing to think about. And if you've ever opened your kid's backpack to find a half-eaten snack from who-knows-when still wrapped up in there, Chomplings are great. They're smaller sticks (the right size to toss in a lunchbox or that little front backpack pocket) with 4 grams of protein and zero sugar.Chomps are made of high-quality ingredients like 100% grass-fed beef, venison, and antibiotic-free turkey. They're also free from the top nine allergens, so you don't have to worry about sending them to school. Check out all the sizes and delicious flavors at Chomps.com/DRBECKY for 15% off plus free shipping.Good Inside is now eligible for HSA/FSA reimbursement with a Letter of Medical Necessity!  We're partnering with Truemed to make the process easy - go to https://www.goodinside.com/fsa-hsa-eligibility/ to learn more.Good Inside Members,  love the podcast and want to keep the conversation going? Starting Tuesday, August 5th, join us every Tuesday at 10:30am for Podcast Club to dive deeper, share reflections, and connect with other listeners.Get the Good Inside App by Dr. Becky: https://bit.ly/4fSxbzkYour Good Inside membership might be eligible for HSA/FSA reimbursement! To learn more about how to get your membership reimbursed, check out the link here: https://www.goodinside.com/fsa-hsa-eligibility/Follow Dr. Becky on Instagram: https://www.instagram.com/drbeckyatgoodinsideSign up for our weekly email, Good Insider: https://www.goodinside.com/newsletterFor a full transcript of the episode, go to goodinside.com/podcast.

The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for the 2026 fiscal year has been released.Tucked inside the Proposed Rule from the Centers for Medicare & Medicaid Services (CMS) is the agency's recommendation to phase out the Inpatient-Only List (IPO) over the course of the next three years.Reporting the lead story on this development during the next edition of Monitor Mondays will be longtime panelist Ronald Hirsch, MD.The weekly broadcast will also include these instantly recognizable features:• 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 healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

It's a Medicaid Madness mess.For many years, Medicaid has been providing support for America's most vulnerable populations. But now, Medicaid finds itself as a pawn, being manipulated for political gain between two opposing forces: those who view the program as a means to an end to reduce government spending, and those who hold the opposite point of view.Who will be the winners and losers? During the next live edition of the venerated Monitor Mondays, senior healthcare consultant Dennis Jones will report on how hospitals can save money in the face of the inevitable Medicaid cuts.Jones, senior director of revenue cycle at Jefferson Health, was among the first of hand-picked subject-matter experts heard nearly 14 years ago on the weekly Internet broadcast produced by RACmonitor.The Monday's broadcast 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: Sitting in for healthcare attorney David Glaser will be attorney Marguarite Ahman, a shareholder in the law offices of Fredrikson & Byron.• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Did you know you might be able to deduct your dog's food, training, vet bills—and even travel—as a business expense?In this episode of Life-Changing Money, Barbara dives into one of the most surprising (and asked-about) tax strategies: how to legally write off your pet in your business. Whether you're a business owner, therapist, real estate investor, or content creator—if your animal plays a role in your work, there might be a way to deduct those expenses.Barbara breaks down six legit ways to deduct pet expenses and what documentation is required to keep it all IRS-compliant. From guard dogs and content mascots to therapy animals and service dogs—this is a must-listen for anyone who wants to keep more of their money while caring for their furry friend.Tune in to hear:How Barbara is deducting her own puppy as a service animal (and how you can too)The difference between emotional support animals vs. service animals (and which one qualifies for medical write-offs)How business owners can legally deduct:Guard dogsPest control animals (like barn cats)Pet mascots/content creatorsTherapy animals in clinical settingsFoster pets via 501(c)(3) organizationsWhy you need a Letter of Medical Necessity (and who can write one)What the IRS requires in terms of tracking, receipts, and documentationHow to use a Medical Expense Reimbursement Plan (MERP) to turn personal medical costs—including pet care—into business deductionsA breakdown of itemized deductions vs. MERPs (and which saves you more)How to avoid crossing the line between personal pet and deductible expenseWant to learn more? Register for the Free Masterclass on Building Family Wealth: https://taxedacademy.com/family  How To Get Involved:Life-Changing Money is a podcast all about money. We share stories of how money has impacted and radically changed the lives of others—and how it can do the same for you.Your host, Barbara Schreihans (pronounced ShREE-hands) is the founder and CEO of Your Tax Coach, and the creator of the Write Off Your Life Course. She is a top tax strategist, business coach, and expert in helping business owners and high-net-worth individuals save millions in taxes while increasing profits.When she's not leading her team, coaching clients, or dreaming up new goals for her company, you can find her drinking coffee, hanging out with her family, and traveling the world.Grab a cup of coffee and become inspired as we hear from those who have overcome and are overcoming their self-limiting beliefs and money mindsets!Do you have a burning question that you'd love to hear answered on a future show?Please email it to: podcast@yourtaxcoach.bizSign Up For Our NewsletterLife Changing Money PodcastGet Tax Help!

Looking back and looking ahead, we must reckon with a major shift in America's judicial landscape: the elimination of the so-called Chevron Deference. Last year, at about this same time, physician and attorney Dr. John K. Hall was the special guest here on Monitor Mondays, and he began his segment explaining the legal concept.Now, more than a year after the U.S. Supreme Court's landmark decision overturning 40 years of judicial precedent and upending statutory construction and enforcement, we must ask, has anything really changed?Dr. Hall will return to examine the changes – or maybe lack of changes – and what we might still expect regarding legal challenges to executive actions.The venerable broadcast 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: Adam Brenman, senior regulatory affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The Transparency in Coverage (TiC) Final Rule represents one of the most significant regulatory shifts in healthcare pricing since the implementation of the Patient Protection and Affordable Care Act.During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will walk you and your team through the comprehensive labyrinth of changes.Recent enforcement developments, including President Trump's Executive Order 14221, directing actual hospital price disclosure within 90 days, also signal an intensified regulatory environment requiring proactive compliance strategies.The venerable broadcast 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: Moesha Baptiste, intern regulatory analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Call it a trifecta, triumvirate, or the Triple Crown of 2025.“Fraud, waste, and abuse” is the current triple-negative buzzword in America's lexicon. And it's being used to describe lots of things. But when that phrase is used by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), what does it actually mean?You'll learn during the next live edition of Monitor Mondays.That's when senior healthcare consultant Dr. Drew Updike – the broadcast's special guest – will report on how the Acting HHS Inspector General (IG) Juliet Hodgkins used that phrase when she recently posted an online promotion in support of the OIG Spring Semiannual report to Congress.The venerable broadcast 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: Matthew Albright, chief legislative government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

Clinical denials by payers for sepsis continues. The problem: the definition of the enigmatic condition does not meet their propriety definitions.Enter Dr. James Kennedy, who will be the special guest during the next live edition of the long-running Monitor Mondays broadcast. Dr. Kennedy will report on his recent conversations with the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, in which the agency described its protocols in amending the Index and Table to fit new diseases and terminology.The venerable broadcast 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: Adam Brenman, senior healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

The nation's Medicaid program has seen better days. Recently, the federal government's program to provide healthcare coverage to America's low-income and vulnerable citizens was used as a bargaining chip as congressional Republicans were in the throes of budget negotiations, facing the daunting task to pass what President Trump calls his “big, beautiful bill:” a package of tax breaks disproportionately favoring the wealthy and spending cuts. The bill, which last week passed in the U.S. House of Representatives, is now making its way through the Senate.Then there was the announcement this midweek that the Deputy Administrator and Director of the Center for Medicaid and Children's Health Insurance Program (CHIP) Services, Drew Synder, was resigning from the federal agency.Reporting on these developing stories during the next live edition of the long-running Internet broadcast Monitor Mondays will be Drew Updike, MD.The venerable broadcast 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 healthcare government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

During the next edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will provide an update on a whistleblower case that some consider “beyond bad.”You'll learn why a Texas rheumatologist who was sentenced to 10 years in prison and three years of supervised release was ordered to forfeit more than $28 million, plus 13 real-estate properties, a jet, and a Maserati GranTurismo sports car.Inman, long considered one of the nation's foremost whistleblower attorneys, will be the program's special guest during the next live edition of the venerable Internet broadcast, coming up at 10 a.m. EST on Monday, June 2, 2025.The long-running broadcast 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.Field Report: Drew Updike will continue his reporting on efforts by the Trump Administration to intervene in healthcare issues – namely the Centers for Medicare & Medicaid Services (CMS) Form 64 related to migrants and Medicaid.

Welcome to a strange new world.Recent tariffs announced by the Trump Administration are likely to impact drug manufacturing, since many drug components are produced outside the U.S., in nations such as in India, giving rise to state laws. Many states limit overseas involvement relative to the Health Insurance Portability and Accountability Act (HIPAA). Florida, for example, prohibits the offshoring of certain patient data, requiring such storage to be within the U.S.Responding to this emerging crisis, the producers of RACmonitor and Monitor Mondays have invited Lexi Morrison, director of operations at MedPharma, to be the program's special guest during the next live edition of the venerable Internet broadcast, coming up at 10 a.m. EST on Monday, May 19.The long-running broadcast 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: Adam Brenman, senior government affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.

On the surface, it was the perfect scam: kickbacks to docs in exchange for public speaking engagements, in order to induce them to prescribe drugs.That's apparently what Gilead Sciences thought.But a whistleblower blew the whistle, and Gilead admitted to paying hundreds of thousands of dollars to high prescribers of their HIV drugs to serve as speakers at programs at luxury restaurants.Famed whistleblower attorney Mary Inman, partner at Whistleblowers Partners, LLP, will report the savory details during the new live edition of Monitor Mondays, coming up at 10 a.m. EST on Monday, May 12.The long-running broadcast 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: Folan Houston, assistant general counsel for Zelis, will report on the news at the intersection of healthcare and congressional action.• Field Report: Dr. Drew Updike continues his reporting on recent efforts by the Trump Administration to prevent providers from undertaking gender-affirming treatments for America's LGBTQ+ population.

The 2021/2023 E/M guideline revisions read: “The evaluation and/or treatment should be consistent with the likely nature of the condition.” Before this, the CPT® guidelines did not discuss medical necessity. Guidance was left to the payers, particularly Medicare, via the Social Security Act. CMS's guidance doesn't necessarily hold regulatory authority. However, it often reflects a new, shared […] The post Medical Necessity Comes Before Coding appeared first on Terry Fletcher Consulting, Inc..

The 2021/2023 E/M guideline revisions read: “The evaluation and/or treatment should be consistent with the likely nature of the condition.” Before this, the CPT® guidelines did not discuss medical necessity. Guidance was left to the payers, particularly Medicare, via the Social Security Act. CMS's guidance doesn't necessarily hold regulatory authority. However, it often reflects a new, shared […] The post Medical Necessity Comes Before Coding appeared first on Terry Fletcher Consulting, Inc..

When auditing Annual Wellness Visits (AWV), is the concept still the same as preventive exams concerning modifier 25? The AWV does not include managing medications or managing conditions. However, the rules need to see medical necessity for the E/M on the same date with a -25 modifier. Remember, patients do not have a share of […] The post AWV and Medical Necessity Extras appeared first on Terry Fletcher Consulting, Inc..

When auditing Annual Wellness Visits (AWV), is the concept still the same as preventive exams concerning modifier 25? The AWV does not include managing medications or managing conditions. However, the rules need to see medical necessity for the E/M on the same date with a -25 modifier. Remember, patients do not have a share of […] The post AWV and Medical Necessity Extras appeared first on Terry Fletcher Consulting, Inc..