Podcast appearances and mentions of nancy beckley

Interview with Nancy Beckley, MS, MBA, CHC How to be a compliance expert? Nancy Beckley shares her expertise on this field and shares her experience throughout the years in her career as a compliance expert. Let's learn and explore more about healthcare compliance. In this episode: 02:10 – QOTD “Be yourself, no one else is qualified.” 03:50 – Intro of Nancy Beckley. 06:00 – Who is Nancy Beckley and her career journey? 12:00 – Adapt and adjust to improve in this evolving world. – Dr. Mike 13:50 – How and where can you get a healthcare compliance certification? 25:50 – Nancy stresses the importance of finding your niche. 26:15 – The MENTOR method. 30:00 – Question: What should a small to medium-sized outpatient company do to start with compliance? 30:10 – Nancy answers the question gives helpful tips on how to start and acquire with compliance. 38:05 – Therapists understanding a solid evaluation is a vital step on having a good therapy compliance program. 41:55 – In compliance, there is a tight circle of collegiality. 47:35 – What was her biggest challenge as a compliance expert and how did she turn it around? 49:30 – Nancy's advice – start writing and speaking. 58:25 – Always remember the word FAST. Visit www.LMS.NancyBeckley.com and www.NancyBeckley.com --- Send in a voice message: https://anchor.fm/althealthcareers/message

Post By: Adam Turteltaub It’s a tough time for post-acute care for a wide range of reasons. As Nancy Beckley explains in this podcast, patients cut off from the outside world have provided not just emotional challenges. They have provided compliance challenges as well. Two issues are of particular note. The first is support of persons with disabilities and ensuring that they are not denied equal access to medical treatments and are getting adequate care. The second problematic area has revolved around religion and access to clergy. Many facilities had banned religious visits, as they had family visits. That led to complaints, and The Office of Civil Rights  has now given direction and continues to announce resolutions that post-acute care facilities need to heed. Listen in to ensure that your organization doesn’t run afoul of the rules, and also to learn more about the growing number of therapists in compliance roles.

While much of today’s healthcare news is righty focused on the efforts to stave off the global coronavirus pandemic, there is other news to report – and Monitor Mondays will have a complete wrap-up on all of it during the next edition of the weekly Internet radio broadcast, while also looking ahead.And given the tendency of the Centers for Medicare & Medicaid Services (CMS) to issue waivers and guidance with a unique style of ambiguity, a great deal of confusion also continues to come from hospitals and health systems in their efforts to remain compliant – while at the same time tending to their mission of delivering patient care amid the crisis. So during this special 60-minute live edition, we’ll also have our panelists standing by to answer your questions.Other segments to be featured during the live broadcast include the following:RAC Report: Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, will file the Monitor Mondays RAC Report.Monday Focus: Kathy Pride, executive vice president of coding and documentation services for Panacea Health, will report on two interim final rules, including an expansion and relaxation of guidelines for telehealth services.Court Report: Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report on two prominent examples of the need for independent regulatory oversight: the removal of the Inspector General of the U.S. Department of Health and Human Services (HHS), and news that Rick Bright, former director of the Biomedical Advanced Research and Development Authority, has filed a whistleblower complaint with the Office of Special Counsel, claiming that he was transferred to a “less impactful position” at the National Institutes of Health (NIH) after he was reluctant to promote the use of drugs such as hydroxychloroquine to treat COVID-19 patients.Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on the status of healthcare legislation associated with the current COVID-19 pandemic.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on regulatory ambiguity during the pandemic.Outpatient Therapy Update: Nancy Beckley, president of Nancy Beckley and Associates, will return to the broadcast to report on inequities for outpatient therapy providers as it pertains to payment, reimbursement, telehealth, and service delivery.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment. Special Report: RACmonitor investigative reporter Edward C. Roche, PhD, JD, will provide a status report on COVID-19 testing in the United States.COVID Q&A: Navigating COVID-19 guidance continues to be a major challenge for healthcare professionals – and that is why Monitor Mondays will devote additional time during this live broadcast to answer your questions. Returning to the broadcast will be Matt Lambert, MD, an emergency medicine physician and chief medical officer for Curation Health.

A federal judge has upheld a lower court’s ruling that the U.S. Department of Health and Human Services (HHS) exceeded its statutory authority when it reduced the 2018 Medicare reimbursement rate for drugs covered by the federal 340B Program. U.S. District Court Judge Rudolph Contreras, sitting in the District of Columbia, issued the ruling recently in the matter of American Hospital Association v. Alex M. Azar, HHS Secretary, ordering HHS back to the drawing board and warning it to act with haste to make a correction. Reporting our lead story during this edition of Monitor Mondays is RACmonitor national correspondent Timothy Powell. Other segments to appear on the broadcast include:Court Report: Two more pharmaceutical companies have agreed to pay $125 million to resolve allegations that they paid kickbacks through co-pay assistance foundations. Famed whistleblower attorney Mary Inman has an update on this story, which she first reported on April 15. Inman is a partner in the London office of Constantine Cannon. Monday Focus: What are the issues when trying to project the results of an audit to a larger population of providers? Senior healthcare analyst Frank Cohen with DoctorsManagement reports on the myth surrounding pass/fail rates for providers. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers. Link for Davids segment: The new guidance about co-location of space in hospital-based space, New DOJ guidance about Cooperation in False Claims Act CasesMonday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment. Links for Dr. Hirsch's segment: PREOPERATIVE MEDICAL TESTING BEFORE CATARACT SURGERY, Reduce Low-Value Preoperative Care

Confusion appears to be hampering important decisions when it comes to patient status, particularly the question of inpatient versus outpatient – and more specifically when it comes to the status of psychiatric patients who are waiting in the emergency department to be transferred to a psychiatric hospital. The subject is not only newsworthy but also one that seems to be causing consternation and frustration.Reporting our lead story during this edition of Monitor Mondays is Kathy Seward, MD, chief medical officer for qlēr Solutions Inc., a telemedicine company providing psychiatric care to patients throughout the United States in partnership with hospitals and health systems. Dr. Seward is a recent addition to the RACmonitor editorial board.Other segments to appear on the broadcast include: Program Integrity Issues: Healthcare attorney Andrew Wachler, a managing partner at Wachler & Associates, reports on Center for Program Integrity (CPI) priorities for 2018 and 2019, including remarks on the various contractors and their methodologies.Court Report: US WorldMeds (USWM) LLC has agreed to pay $17.5 million to resolve allegations that it violated the False Claims Act by paying kickbacks to patients and physicians to improperly induce prescriptions of its drugs, Apokyn®, and Myobloc®. USWM is a pharmaceutical manufacturer headquartered in Louisville, KY. Famed whistleblower attorney Mary Inman reports this developing story. Inman is a partner in the London office of Constantine CannonHot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers. Links from Davids Segment Center for Clinical Standards and Quality/Quality, Safety & Oversight Group 4-4.000 - COMMERCIAL LITIGATIONMonday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

The Centers for Medicare & Medicaid Services (CMS) is inviting state Medicaid directors to partner with them to test new approaches to better serve those who are dually eligible for Medicare and Medicaid.More than $300 billion is spent annually by CMS and states to care for the dual-eligibles, and many of the 12 million of those beneficiaries have multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. Could the CMS initiative suggest cost-cutting, administrative burden reductions, or true innovation? RACmonitor national correspondent J. Paul Spencer, a senior health consultant for DoctorsManagement, reports our lead story during this edition of the long-running Monitor Mondays live broadcast.Other segments to appear on the broadcast include:Court Report: Famed whistleblower attorney Mary Inman reports on the guilty verdict handed down Thursday by a federal grand jury in Boston that found Insys Therapeutics founder John Kapoor and four other executives guilty of criminal racketeering in bribing physicians to prescribe powerful opioids to patients who didn’t need them. Inman is a partner in the London office of Constantine Cannon.2020 IPPS Proposed Rule: Social determinants of health (SdoH) are back in the news, since CMS is proposing to make homelessness a CC (complication and comorbidity) for the purposes of Inpatient Prospective Payment System (IPPS) coding. Does the CMS action signal that SDoH are a growing concern in the nation’s healthcare landscape? Continuing our reporting on this hot topic is nationally recognized SDoH authority and author Ellen Fink-Samnick.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will report on all the latest hot topics and will also conduct the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

News reports have been circulating of late about proposed state and federal legislation targeting healthcare “surprise” balance billing.Reporting our lead story during this edition of Monitor Mondays will be Matthew Albright, chief legislative affairs officer for Zelis. The former Director of the Administrative Simplification Group for the Centers for Medicare & Medicaid Services (CMS), Albright will also report on drug rebate discussions and how those discussions are being impacted by broader reform proposals such as Patient Protection and Affordable Care Act (PPACA) stabilization, outright repeal, and Medicare-for-all.Other segments to appear on the broadcast include:Monday Focus: Targeted Probe-and-Educate (TPE) audits are the Monday Focus, healthcare attorney Knicole Emanuel returns to the broadcast to report on what is believed to draconian efforts by TPE auditors. Emanuel, a member of the RACmonitor editorial board, is a partner in the Potomac Law Group.IPPS Proposed Rule: Reporting on the release of the CMS proposed 2020 Inpatient Prospective Payment System (IPPS) rule for acute-care hospitals will be ICD10monitor contributing editor Laurie Johnson, a senior healthcare consultant with Revenue Cycle Solutions. See Laurie's Handout here.FY 2020 Proposed Rule TablesHot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics, including confusion surrounding the former functional G codes once used for Functional Limitation Reporting (FLR). Beckley also conducts the Monitor Mondays Listener Survey.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

New from the Office of Medicare Hearings and Appeals (OMHA) is ECAPE—an electronic case management and workflow system designed to help reduce the backlog of appeals. ECAPE is expected to streamline and manage electronic filings, exhibiting, scheduling, and general case management. Reporting this breaking news story is Andrea Monson, who is the head of the ECAPE project for OMHA. Other segments to appear on the broadcast include:Monday Focus: Healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will provide context and perspective to the ECAPE system at the OMHA.IFF Report: One of the nation’s foremost authorities on inpatient rehabilitation (IRF) Angela Phillips will report on the proposed 2020 Inpatient Prospective Payment System (IPPS) for IRF that CMS posted on Wednesday. The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on compliance issues associated with robotic surgery.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and conducts the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.

In the final installment of a two-part series on prescription drug prices, during this edition of Monitor Mondays we will report on the latest initiative on a new “war on drugs” – the anticipated rollout by the Health Resources and Services Administration (HRSA) of a new secure website that hospitals, clinics, and health centers can use to see what price they should be paying for any drug covered under the 340B federal drug program. Reporting on this development will be Maureen Testoni, Esq., president and CEO for 340B Health. Other segments to appear on the broadcast include:Monday Focus: J. Paul Spencer, senior healthcare consultant for DoctorsManagement and a RACmonitor national correspondent, reports on the latest update to the American Medical Association’s (AMA’s) 2021 evaluation and management (E&M) changes. https://www.racmonitor.com/an-overview-of-ama-s-e-m-revisions-for-2021/Whistleblower Report: MedStar Health of Maryland has agreed to pay the government 35-million dollars to resolve allegations of under the False Claims Act that it paid kickbacks to a cardiology group. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and conducts the Monitor Mondays Listener Survey. Click to view SNF Prospective Payment PDFRisky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers. Monday Rounds: Howard A. Stein, DO, associate director of medical affairs for Centrastate Medical Center, makes his Monday rounds in the absence of Ronald Hirsch, MD.

In the first portion of a two-part series on prescription drug prices, during this edition of Monitor Mondays we report on the Centers for Medicare & Medicaid Services (CMS) Drug Spending Dashboards with data for 2017.First released in May of last year, the new dashboards include information on manufacturers that are responsible for price increases, plus pricing and spending data for thousands of more drugs across Medicare Parts B and D and Medicaid. Reporting Part I of the series will be Timothy Powell, a regulatory expert and a RACmonitor national correspondent. During Part II, scheduled for April 1, Maureen Testoni, president and CEO for 340B Health, will report on the state of the union of the drug discount program.Other segments to appear on the broadcast include:The Roche Report: Edward C. Roche, RACmonitor investigative reporter and New York attorney, reports on the use of artificial intelligence (AI) to detect fraud in social health insurance programs.CHS Whistleblower Lawsuit: Two former Community Health Systems (CHS) employees have alleged that CHS submitted hundreds of millions of dollars in false claims to the U.S. Department of Health and Human Services (HHS) for federal incentive payments under the CMS interoperability program for electronic health records. The whistleblowers allege that CHS received more than $450 million in incentive payments between 2012 and 2015. Famed whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, has the latest news on this major story.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and will conduct the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, makes his Monday Rounds with another installment of his popular segment.

Could the Empire State be among the first to introduce a single-payer healthcare system?The latest news coming from Albany would seem to indicate that; now that both state legislative branches are under control of the Democrats, such an option is likely viable. Currently on the table is the New York Health Act (NYHA), which is proposed to extend coverage to New Yorkers who currently have no access to healthcare.Reporting our lead story during this episode of Monitor Mondays will be Dennis Jones, a New Yorker and the administrator of patient financial services at Montefiore Nyack Hospital in Nyack, N.Y.Other segments to appear on the broadcast include:Monday Focus: Revised E&M Codes: As expected, the American Medical Association’s (AMA’s) CPT® editorial board last month approved major changes to documentation and code selection guidelines for evaluation and management (E&M) codes. The changes were announced last week and are expected to become effective in 2021. Reporting this developing story is Shannon DeConda, founder and president of the National Alliance of Medical Coding Specialists—NAMASWhistleblower Report: Walgreens is facing a whistleblower’s False Claims Act challenge. The lawsuit alleges that pharmacies that the giant retail purchased in 2012 overcharged Medicaid for generic drugs by steeply discounting them to cash-paying customers. Famed whistleblower attorney Mary Inman, a partner in the London office of Constantine Cannon, has the latest news on this major story.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Extrapolation Changes: Part II: The Centers for Medicare & Medicaid Services (CMS) made significant changes in statistical sampling methodology for overpayment estimation. Healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, continues reporting on the changes and what they mean to providers.

The preponderance of ambiguously worded regulations from federal agencies – think the Centers for Medicare & Medicaid Services (CMS) – will be at the center of a major legal challenge coming March 26 to the nation’s highest court, and you’ll hear the details here during this edition of Monitor Mondays.That’s when Jennifer Gustafson will report our lead story, focusing on the U.S. Supreme Court (SCOTUS) taking up the case of Kisor vs. Wilkie (U.S. Marine James Kisor vs. the U.S. Department of Veterans Affairs).The dispute is over denied Veterans Affairs (VA) benefits. In 1997, SCOTUS ruled that generally, federal courts are required to accept an administrative agency’s interpretation of its own ambiguous relations; this rule today is known as Auer deference.Gustafson is a founding shareholder with The Health Law Partners, representing hospitals, health systems, hospices, home health agencies, physicians, and other healthcare providers and suppliers in an array of legal matters.Other segments on the broadcast include:Monday Focus: LTACH vs. Managed Care: Limiting access of Medicare patients to long-term acute care (LTAC) facilities by health insurance companies; reported on by Marvin Mitchell, the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles.Prime Healthcare: Prime Healthcare Services will pay $65 million to settle a federal whistleblower lawsuit that accused the California hospital chain of Medicare fraud. Famed whistleblower attorney Mary Inman, has the latest news on this major story.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, maks his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also be following up on his segment last Monday on how to bill for inpatient services when there is no admission order.

“It is unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place," President Donald Trump told members of Congress during his State of the Union address on Wednesday. "This is wrong, unfair, and together we will stop it. We will stop it fast," the President warned. During his address, the President also pledged to end the HIV epidemic in the nation.Both issues will be discussed during this edition of Monitor Mondays, when Maureen Testoni, president and CEO for 340B Health, returns to the broadcast. Testoni is considered to be one of the nation’s leading experts on the 340B drug pricing program and was recently was recognized as one of the “100 Most Influential People in Healthcare” by Modern Healthcare.The broadcast rundown also will include:Medicare Advantage: Are managed care beneficiaries being deprived of an important benefit? Enrolling in MA plans, beneficiaries expect to receive the same benefits as in traditional Medicare. But as providers move toward DRG payments, MA plans decline authorization for long-term acute care (LTAC) for patients with prolonged respiratory requirements and those with prolonged needs. MA plans feel that these patients should remain in the hospital under the original DRG payment. Reporting on this developing story is Howard Stein, MD, associate director of medical affairs and physician advisor in care management at CentraState Medical Center in Freehold, N.J.Anthem Lawsuit: Nationally renowned whistleblower attorney Mary Inman reports on the recent class action lawsuit filed against Anthem Health.Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on a scientific breakthrough in DNA sequencing.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on problematic issues facing providers.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Monday Rounds: Juliet Ugarte Hopkins, MD, Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin makes her Monday rounds while substituting for Dr. Ronald Hirsch.

Are you experiencing an increase in calls from payers giving you two to three hours to send clinical documentation required to obtain an authorization, or else your claim will be denied? Are you being told you cannot have a peer-to-peer session because your request was considered late? Are you hearing that you must have everything — “pre-denial” or “pre-auth” — done within 72 hours of notification, only they typically wait until they only have three hours left? During this edition of Monitor Mondays, listen and learn what Val Kraus and his team at one major Midwest health system are doing to reduce the impact of these scenarios.The broadcast rundown also will include:Monday Focus: RACmonitor investigative reporter and New York attorney Edward Roche reports on what he says is the death of statistical extrapolation of Medicare audits by way of qui tam demands.Opioid Crisis: The Purdue Lawsuit: Nationally renowned whistleblower attorney Mary Inman, featured in The New Yorker, returns to the broadcast to report on the major opioid lawsuit involving Purdue Pharma. The lawsuit is part of a national effort to force pharmaceutical companies to pay, in part, for the damage inflicted as a result of opioid healthcare crisis.Risky Business: Healthcare attorney David Glaser returns to Monitor Mondays with his popular segment, in which he reports on Medicare Advantage and other problematic issues facing providers.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.Register now for this important news broadcast coming up at 10 a.m. EST on the first Monday of the month, Feb. 4, 2019.

Seeking to clarify its original MLN Matters guidance on total knee arthroplasty (TKA) issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an updated memo on the subject on Thursday.The latest version contains misdirection and ambiguity, the likes of which was first reported by RACmonitor, prompting CMS to rescind its initial memo. Reporting our lead story during the next edition of Monitor Mondays will be R. Phillip Baker, MD, medical director of case management at Self Regional Healthcare.The broadcast rundown also will include:Monday Focus Report: Blockchain: Distributed ledger systems (DLS), also known as blockchain, will be the Monday Focus when RACmonitor investigative reporter and New York attorney Edward Roche will report on new healthcare technologies we can expect to see in 2019.War on Drugs: The U.S. Department of Justice announced this week that Walgreens Boots Alliance agreed to pay $269.2 million to settle two healthcare fraud lawsuits alleging that Walgreens overbilled the government. In a related matter, United HealthCare Services filed a federal lawsuit last week against more than 40 drug companies, alleging they violated federal and state antitrust laws. Whistleblower attorney Mary Inman will report on both lawsuits.Risky Business: Healthcare attorney David Glaser will return to Monitor Mondays with his popular segment “Risky Business,” in which he reports on problematic issues facing providers.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

On Tuesday, the Healthcare Association of New York (HANY) informed its reported 210 member hospitals that the Empire State would not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2.Dennis Jones, the administrator of patient financial services for Montefiore Nyack hospital, was there Tuesday when HANY made the announcement during its regularly scheduled managed care advisory group meeting. Jones, who was among the earliest correspondents to join Monitor Mondays in 2010, will return to the broadcast this coming Monday and report on this newly developing story. Also reporting on Sepsis-3 will be Denise Wilson, vice president of Intersect Healthcare + AppealMasters.The broadcast rundown also will include:False Claims Act: Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, will report on Intermountain taking its challenge of False Claims Act (FCA) to the Supreme Court.The Audit Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, will report on the latest activities by auditors, including the Recovery Audit Contractors (RACs).Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

2019 is shaping up to be another tumultuous year in healthcare. Decisions being made in Washington 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 in front of the issues that will alter the delivery of healthcare now and for the next decade.Monitor Monday host and RACmonitor Publisher Chuck Buck will have the following all-star lineup of experts on hand to tell you what to watch out for in 2019 during the next edition of the weekly Internet broadcast:Duane Abbey, PhD; Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Frank Cohen, MPA; William Dombi, Esq.; Knicole Emanuel, Esq.; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; Angela Phillips, PT; Lauren Riplinger, JD; Edward M. Roche, PhD, JD; and Andrew Wachler, Esq.All this and more will be coming your way as we help you anticipate what’s ahead in what is be expected to be another tumultuous year of healthcare auditing and compliance.

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, 2019.The broadcast rundown also will include:Monday Focus: Lawmakers in Michigan have approved permanent medical marijuana licensing rules, including a provision to allow dispensaries to deliver the drug to cardholders' homes. RACmonitor investigative reporter and New York attorney Edward Roche will report on the adoption of cannabis therapy in Medicare.The Audit Report: Becky Charlton, RN, denials/appeals coordinator at Blessing Hospital in Quincy, Ill., reports on her hospital’s plans to appeal a denied claim for an inpatient stay by KEPRO,a Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). The episode generated national attention when it was reported that KEPRO revealed the existence of a secret CMS memo.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.100 Percent Error Rates, Every time: Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on why he’s suspicious when auditors that review claims report 100 percent error rates, all the time.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

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 & Medicaid Services (CMS) Medicare Advantage Group for the last two years, and has gotten them to put in writing statements noting that these plans have to follow original Medicare regulations for non-contracted facilities. The broadcast rundown also will include:Medicare Advantage Report: A central concern about the capitated payment model used by Medicare Advantage Organizations (MAOs) is the financial incentive for them to inappropriately deny access to services and reimbursements for services rendered in order to increase their profits, according to Knicole Emanuel, partner at the Potomac Law Group, who reports on this developing story.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron answers listeners’ questions from previous broadcasts on subjects that could be potentially troublesome.“Hello, Are You There?” Senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement, reports on problems now being created because a Quality Integrity Contractor (QIC) failed to respond to his appeal issues.When Minutes Count: Phones lit up and social media seemed to explode last week when CMS announced it might not allow minutes to count when therapy services are provided by students. The exclusive story was reported on RACmonitor by nationally renowned inpatient rehabilitation facility (IRF) expert Angela Phillips, the president and CEO of Image and Associates. Phillips reports on the details behind the news that is rocking IRF providers’ worlds.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, returns to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

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 story will be William Dombi, president of the National Association for Home Care and Hospice.The broadcast rundown also will include:Death by Cyber, Part III: RACmonitor investigative reporter and New York attorney Edward Roche will report on how healthcare IT adds to the cost of healthcare, but without offering benefits.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will return to report on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment.

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: Famed whistleblower attorney Mary A. Inman, a partner at Constantine Cannon’s London office, reports that DaVita Medical Group has agreed to pay $270 million to CMS to settle False Claim Act allegations over questionable billing practices that led Medicare Advantage plans to receive inflated Medicare Part C risk adjustment payments.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.Legislative Update: In California, there’s a bill on the November ballot (SB 1152) that would amend an existing law by establishing a uniform discharge planning process that takes into account the unique needs of homeless patients. Reporting on this proposition is Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital, east of Los Angeles.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

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: Targeted Probe and Educate Audits continue to generate confusion and concern. Returning to report on this developing story is healthcare attorney Andrew Wachler who has a follow-up to his reporting last Monday on Monitor Monday.Death by Cyber, Part II: RACmonitor investigative reporter and New York attorney Edward Roche reports on how healthcare IT enables pharmacy benefit managers to keep drug prices high.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.

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), referral to a Recovery Audit Contractor (RAC), suspension of Medicare payments, or even revocation of Medicare billing privileges.Reporting our lead story during this edition of Monitor Mondays is healthcare attorney Andrew Wachler, managing partner of Wachler and Associates. Wachler offers some practical tips and strategic approaches for responding to TPE audits to reduce claim denials.The broadcast rundown also will include:Developing Story: PIM Change: CMS is proposing major changes to the Program Integrity Manual (PIM) – changes that will take effect Jan. 1, 2019. Senior healthcare analyst Frank Cohen, director of analytics and business intelligence for DoctorsManagement, reports on the changes involving sampling and extrapolation.Death by Cyber: RACmonitor investigative reporter and New York attorney Edward Roche suffered a life-threatening medical emergency while in Barcelona, Spain. Roche reports on the one mainstay of America’s hospitals that was missing while he was hospitalized and ultimately experienced a complete recovery.Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility.Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest with TPE audits.Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment.Register now for this important news broadcast coming up at 10 a.m. EST on Monday, Oct. 15.

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 Care and Hospice. The broadcast rundown also will include: Monday Focus: The newest compliance issue to gain national attention involves the T codes. As of Oct. 1, providers are required to document clients who might be at risk of sex and labor exploitation. Reporting on this story is nationally recognized authority on the social determinants of health (SdoH), Ellen Fink-Samnick. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the latest hot topics. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Payment Report: Are small, independent providers being forced by CMS to increase their size so that there is enough activity to have the averaged national payments break even, or be profitable? Author, educator, and consultant Duane Abbey, president of Abbey and Abbey Consultants, Inc., reports on this timely issue. The Hospice Report: Are referrals to hospice frequently the result of misunderstandings of the purpose of hospice? And why the rush to hospice if death is imminent? Marvin D. Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in California, reports on this critically important subject.

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: Giant healthcare insurer UnitedHealth is back in the news, this time for being named in a lawsuit involving Medicare Advantage. Nationally recognized whistleblower attorney Mary Inman, partner in the London office of Constantine Cannon, reports the details of this developing story. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Florence Watch: Marvin D. Mitchell, director of case management and social services at San Gorgonio Memorial Hospital, reports on the long-term consequences of Florence and its impact on Medicare and Medicaid beneficiaries. Monitor with us™

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 posting on the HHS website. HHS also said it has positioned about 230 medical personnel in North Carolina and Maryland to help communities that may need extra medical support. In addition, HHS reported that it is working to make more ambulances available to help evacuate hospitals and nursing homes. During this edition of Monitor Mondays: Reporting live from Charlotte, North Carolina will be Sharon Easterling, CEO for Recovery Analytics, LLC. Also on the broadcast will be Ellen Fink-Samnick, a nationally recognized expert on the social determinants of health and former emergency department and intensive care unit case manager. The broadcast rundown also will include: Monday Rounds: Daniel Zirkman, MD makes his monday rounds from his facility, CarolinaEast Health System in New Bern, North Carolina where he is the chief physician advisor. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Compliance Report: Regulatory expert Timothy Powell, CPA, RACmonitor national correspondent, reports on compliance issues surrounding hospital readmissions. Monitor with us™

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 established patient visit codes 99212-99215. Code 99211 would also be paid a lower rate. The level 1 codes don’t get the flat rate, because they don’t require the presence of a physician. Making a final stand in opposition to the proposed changes during this edition of Monitor Mondays will Dr. Steven J. Meyerson, board-certified in internal medicine and geriatrics, and Holly Louie, past president of the Healthcare Business and Management Association. The broadcast rundown also will include: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Monday Focus: Social Determinants of Health (SdoH) are coming into sharp focus, as Tropical Gordon impacted parts of the Central Gulf Coast this week. It brought with it memories of Hurricane Harvey and its impact that is still being experienced in Houston, especially among the poor, the unemployed, and the disenfranchised – those who are predisposed to SDoH. Reporting on the compliance issues surrounding SDoH will be nationally recognized topic authority Ellen Fink-Samnick. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Monitor with us™

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 were "pushing doctors to make unwarranted diagnoses" and "using leading queries to change doctors' original diagnoses." Reporting our lead story during this edition of Monitor Mondays will be False Claims Act attorney Mary Inman, partner in the London law office of Constantine Cannon. Also on board reporting the data analytics associated with this developing story will be senior healthcare analyst Frank Cohen, director of business intelligence and analytics for DoctorsManagement. The broadcast rundown also will include: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Monday Focus: Michael Salvatore, MD, FACP reports on the ancient practice of alchemy and how its modern-day equivalency is turning health into disease. Dr. Salvatore is the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron continues his reporting on the perennial question, “should I refund an overpayment?” He will pose the question as a listener quiz. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics. Monitor with us™

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 a lower rate. The level 1 codes don’t get the flat rate, because they don’t require the presence of a physician. Reporting this developing story during this edition of Monitor Mondays will be Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as president of coding and billing services and a partner at DoctorsManagement, LLC. The broadcast rundown also will include: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Monday Focus: Lori O’Hara, the lead of the additional documentation request (ADR), appeals, and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, reports on the impact of the Inpatient Prospective Payment System (IPPS) final rule as it pertains to skilled nursing facilities. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. IRF Report: One of the nation’s most respected authorities on Inpatient Rehabilitation Facility (IRF) provider issues, Angela Phillips, president and chief executive officer for Images & Associates, reports on IRF provisions that will be impacted by the IPPS final rule. Monitor with us™

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: RACmonitor Legislative Analyst Emily Evans, managing director of health policy for Washington, D.C.-based Hedgeye, reports on the latest developments of the Recovery Audit Contractors (RACs). Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, anchors the broadcast. Nancy will also report on all the latest hot topics. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Dr. Hirsch will also present the Monitor Mondays Listener Survey. Monitor with us™

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 Group. The broadcast rundown also will include: False Claims Act Report: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on Health Quest. The system and some of its subsidiaries have agreed to pay more than $14.7 million to the federal government and an additional $895,427 to the state of New York to resolve False Claims Act allegations that they submitted claims to government payers for evaluation and management (E&M) services that were billed two levels higher than was supported by the medical record. IRF Report: One of the nation’s leading Inpatient Rehabilitation Facility (IRF) authorities, Angela Phillips reports on the fact that IRFs that received a notice of non-compliance and believe the notice is in error have only until Aug. 7, 2018to submit a request for reconsideration. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Monitor with us™

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 Ugarte Hopkins, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Hopkins will also report on structured interdisciplinary bedside rounds (SIBRs), an emerging practice that allows collaboration with the care team on a daily basis. Providing a first-person perspective on the role of case managers as registered nurses in the ED will be Kathleen K. Borchard, an RN case manager at Waukesha Memorial Hospital, also in Wisconsin. The broadcast rundown also will include: RAC Report: Healthcare attorney Knicole Emanuel, a partner at the Potomac Law Group, has the latest news on the Recovery Audit Contractors (RACs). Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on the 2019 Proposed Medicare Physician Fee Schedule’s impact on outpatient therapy. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, reports on the 2019 Proposed Medicare Physician Fee Schedule released by CMS on Thursday. Monitor with us™

The state of Kentucky has introduced Medicaid work requirements. And the trend seems to be proceeding fast and furiously in other states looking to cut health and behavioral health benefits of Medicaid enrollees, with officials saying the costs can’t be met otherwise. Kentucky eliminated vision and dental benefits to 500,000 Medicaid enrollees within 36 hours of the federal decision. Imagine the impact to the readmissions quagmire if benefits continue to be cut for the most vulnerable and disenfranchised members of society, or those most impacted by the social determinants of health (SdoH). These costs are already eye-raising: $1.7 trillion is being spent annually on 5 percent of the population. Readmission penalties are barely being managed across all hospitals, especially the safety net facilities. What will the continued impact of forcing shifts in Medicaid benefits be for the patients who need them most? Reporting on this latest development during the next edition of Monitor Mondays is nationally recognized SDoH expert Ellen Fink-Samnick, author, consultant, and founder of EFS Supervision Strategies, LLC. The broadcast rundown also will include: Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, has an update on the largest-ever healthcare bust, involving more than $2 billion in fraudulent billings. According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Monitor with us™

The Office of Medicare Hearings and Appeals (OMHA) has implemented the long-awaited expansion to its Settlement Conference Facilitation (SCF) process. The process provides appellants and the Centers for Medicare & Medicaid Services (CMS) an opportunity to discuss a mutually agreeable resolution for claims appealed to the administrative law judge (ALJ) or Medicare Appeals Council (Council) levels of appeal. Reporting our lead story during the next edition of Monitor Mondays will be healthcare attorney Erin Diesel Roumayah with Wachler & Associates. The broadcast rundown also will include: Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, will report on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, will continue to report on the vexing issue of Medicare Advantage. Special Assignment: Author, educator, and consultant Duane Abbey, president of Abbey & Abbey Consultants, Inc., will report on the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.r, a senior healthcare consultant for DoctorsManagement, will continue to report on the vexing issue of Medicare Advantage. Monday Rounds: Christopher Halleman, DO, physician advisor at the Brundage Group, will be making his Monday Rounds, substituting for Dr. Ronald Hirsch, who is on assignment. Monitor with us™

The National Institutes of Health (NIH)is expected to receive an additional $500 million to spend annually on pain management and opioid use. On Tuesday, the agency published details as to how the infusion of additional money will be used as part of a program titled “Helping to End Addiction Long Term (HEAL)." Earlier this week, the Centers for Medicare & Medicaid Services (CMS) approved facet joint injections for auditing, warning that auditors will review medical documentation to determine that services were medically reasonable and necessary. Reporting on this latest development will be American Medical Association (AMA) author and consultant Deborah Grider. Grider will also preview her upcoming webcast on the coding and documentation of pain management injections to avoid audits and takebacks. Other segments to be featured on the broadcast include: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Special Assignment:Senior healthcare analyst Frank Cohen will return to the broadcast to continue his reporting of alleged bias he is uncovering in extrapolation audits Monitor with us™

The subject of total knee replacement (TKR) continues to reverberate. In this edition of Monitor Monday, Lori O’Hara, the lead of the ADR, appeals and clinical review team for Ensign Services, a provider of skilled nursing and assisted living services, will offer the perspective of a long-term care provider. Her position is that a TKR patient either needs medical oversight or they do not. The question of the proper environment, O’Hara answered by finding where the patient’s medical and functional presentation intersects the lowest level of safe care. The broadcast rundown also will include: E&M Services: Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS), reports on E&M levels four and five. Monday Newsmakers: Tim Brundage, MD, medical director at the Brundage Group, reported live from the ACDIS convention taking place in San Antonio, Texas. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reported on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser, with Fredrikson & Byron, reported on another example of a potentially troublesome issue that could pose a risk to your facility Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continues to report on the vexing issue of Medicare Advantage. Monitor with us.™

The Health Resources and Services Administration (HRSA), which administers Section 340B of the Public Health Service Act, has published a proposal to delay for another year the ceiling price and civil monetary penalties regulation that was originally issued by the outgoing Obama Administration in January 2017. It was formally published on Monday. National Correspondent Timothy Powell reported our lead story on this episode of Monitor Mondays on 340B. The broadcast rundown also will include: Monday Focus: Nationally recognized whistleblower attorney Mary A. Inman, partner at Constantine Cannon’s London office, reported on a whistleblower case that is attracting unprecedented media coverage—the nurse who knew too much. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, reported on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported on another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays National Correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continued to report on the vexing issue of Medicare Advantage. Monitor with us.™

The dust has yet to settle from last week’s posting by the Centers for Medicare & Medicaid Services (CMS) of the 2019 Medicare Inpatient Prospective Payment System (IPPS) proposed rule, and already Inpatient Rehabilitation Facility (IRF) providers appear to be experiencing relief not typically associated with other proposed rule changes. For them, the proposals from CMS for FY 2019 reflect some positive changes related to reductions in paperwork and, if finalized, they will provide some easing of the workload. One of the nation’s most respected authorities on IRF provider issues, Angela Phillips, president and chief executive officer for Images & Associates, reported on the proposed IRF provisions in the IPPS during this edition of Monitor Mondays. The broadcast rundown also will include: Monday Focus: RACmonitor Legislative Analyst Emily Evans, managing director of health policy for Washington, D.C.-based Hedgeye, reported on what she sees as major themes of the Trump administration’s rulemaking that has been reflected in the proposed rule, including administration burden reductions, price transparency, and meaningful use measures. Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, made his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, reported on all the latest hot topics and presented the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reported another example of a potentially troublesome issue that could pose a risk to your facility. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer, a senior healthcare consultant for DoctorsManagement, continued to report on the vexing issue of Medicare Advantage. Monitor with us.™

Could non-physician practitioners (NPPs) be the next target of auditing by the Centers for Medicare & Medicaid Services (CMS) and private payer auditors? While physicians reportedly represent nearly a million targets for audits, add in another couple of hundred thousand nurse practitioners (NPs) and physician assistants (PAs) and target acquisition becomes that much richer. And in their minds, so do the auditors, according to Frank Cohen, director of analytics and business intelligence for DoctorsManagement, who reports on his latest findings during this episode. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO of Nancy Beckley and Associates, reports on all the latest hot topics and present the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Medicaid Report: Healthcare attorney Knicole Emanuel, partner in the Potomac Law Group, returns to the broadcast with the final installment of her exclusive two-part reporting on a state-by-state review of states' Medicaid regulatory oversight. Monday Focus: Former First Lady Barbara Bush died Tuesday at age 92 at her home in Houston, having decided to decline further medical treatment for health problems and instead to focus on "comfort care." Reporting on palliative care is Michael A. Salvatore, MD, physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. Salvatore is a member of the RACmonitor editorial board. Monitor with us™

Judge James E. Boasberg of the United States District Court for the District of Columbia has ordered the American Hospital Association (AHA) to propose specific recommendations for reducing the Medicare appeals backlog of appeals at the Administrative Law Judge (ALJ) level. Reporting this developing story is healthcare attorney Andrew Wachler, Esq., managing partner at Wachler and Associates. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, report on all the latest hot topics and presents the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. Consumer Alert: New Medicare beneficiary identification cards are scheduled to be mailed from the Centers for Medicare & Medicaid Services (CMS) this month to beneficiaries. And with the new cards come new scams. Author, educator, and consultant Duane Abbey will report on the new cards and the expected scams on bilked seniors. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement. Monitor with us™

Telemedicine, considered to be an electronic lifeline for rural healthcare, is a rapidly growing sector of health care in the United States that has recently gone through a significant expansion. Returning to Monitor Mondays to provide an update to his October 2017 report on the CHRONIC Act and MedPac's report on Telemedicine, is attorney Dale C. Van Demark, a partner at McDermott Will & Emery in Washington, D.C. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. 340B Update: Monitor Mondays national correspondent Timothy Powell, CPA, reports on the status of the controversial 340B drug program. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement. Monitor with us™

Diving deep into the datasphere, senior healthcare analyst Frank Cohen comes up for air in order to report on a new approach he and his team of data experts have developed to predict the likelihood of an audit. While he claims that his team is not yet predicting billing errors, he does report that many of the variables being used to do so can also be used to forecast audits. During this episode Cohen, director of analytics and business intelligence for DoctorsManagement, reports on his latest findings, which could help you and your facility ward off an audit. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on another example of a potentially troublesome issue that could pose a risk to your facility. IRF Update: Angela Phillips, one of the nation's foremost authorities on inpatient rehabilitation facilities (IRFs), reports on all the buzz about Medicare's most recent clarifications to contracted auditors related to auditing therapy minutes for IRFs. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement. Monitor with us™

Patients and providers are reeling in Ohio, given the new Anthem BlueCross BlueShield emergency department (ED) policy, allowing the payer to decline claims for non-emergency ED visits. Advocates caution that Ohio patients might not visit the ED, fearful of not having their visits covered. Former ED physician-turned healthcare consultant Erica Remer, herself an Ohioan, reports on this developing story. Another headline grabbing story is the reported lawsuit filed by Envision Healthcare against UnitedHealthcare (UHC). Envision is using the giant insurer alleging the UHC "unilaterally" lowered payments of Envision's contracted physicians, according to Axios. Healthcare attorney Mary Inman, a partner at Constantine Cannon, reports on this developing story, calling in from the firm's London office. Yet another story about UHC is reported by Shannon DeConda, founder and president of the National Alliance of Medical Auditing Specialists (NAMAS). UHC, DeConda reports, is cracking down on emergency ED service codes of Level 4 and 5. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns to report on all the latest hot topics and the Monitor Mondays Listener Survey. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a developing story that some facilities are receiving CERT letters containing misleading information. Monitor with us™

RACmonitor was founded in 2008 to provide news and information for healthcare providers on the emergence of the government’s Recovery Audit Contractor (RAC) program. From a Centers for Medicare & Medicaid Services (CMS) demonstration in that year, and continuing to the national rollout in 2010 (coincidentally, the year of Monitor Mondays’ national debut), we have been reporting on activities not only of the RACs, but also the Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), and the Quality Improvement Organizations (QIOs). But why, after nearly 10 years, do these auditors still tend to get auditing wrong? Providing insight into this issue during this edition of Monitor Mondays is healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, returns and reports on all the latest hot topics and the Monitor Mondays Listener Survey. News Update: RACmonitor national correspondent Timothy Powell reports on the move by UnitedHealthCare to adjust or deny emergency department (ED) claims submitted with levels four and five evaluation and management (E&M) codes. RACmonitor broke that story with Dr. Hirsch in December of last year. Auditing Report: Kristi Pollard, senior coding consultant at Haugen Consulting Group, reports on a top audit finding uncovered by her firm: discrepancies in secondary diagnosis assignment on outpatient claims. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron shares another example of a potentially troublesome issue that could pose a risk to your facility. Monitor with us™

"The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians," reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. "These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient." During this episode of Monitor Mondays Dr. Hopkins makes the case for abandoning your P2P process if the results are not satisfactory. Might the pressure of P2Ps even be contributing to some physicians considering opting out of Medicare? Duane Abbey, PhD, president of Abbey and Abbey Consultants, Inc., will review the complexities of compliance facing physicians and practitioners who might consider throwing in the towel. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey. Hospice Report: Theresa Forster, BA, vice president for hospice policy and programs for the National Association of Home Care and Hospice, reports on changes to the CMS Hospice Compare program announced Thursday. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a recent memo from the U.S. Department of Justice offering good news for some providers. Monitor with us™

Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility? Mary Beth Pace, vice president of care management at Trinity Health and the special guest on this edition of Monitor Mondays, frames the conundrum as a hypothetical patient/caregiver conversation: "we are going to do major surgery on you, but we are not sure if we will keep you after surgery – and oh, by the way, there will be a copay and deductible either way, we don't know which one. But don't worry, it will be a good thing to have your knee in working order again." Tune in to the podcast as she reports on how TKRs are admitted at Trinity. Also reporting on this timely subject is Jeffrey Pilger, MD, a board-certified lead physician advisor affiliated with St. Elizabeth Healthcare Edgewood in Edgewood, Ky. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey. Office of Civil Rights Report: Rita Bowen, with MRO, is a nationally recognized healthcare privacy expert. Bowen reports on the latest initiatives by the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), including updates on the HIPAA Audit Program, patient access guidance, and resolution agreements. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron shares another example of a potentially troublesome issue that could pose a risk to your facility. Prior Authorization: Betty Lengyel-Gomez with the Healthcare Administrative Technology Association (HATA) reports on research HATA has conducted to remove barriers to the adoption of prior authorization transactions. Lengyel-Gomez is the industry relations and regulatory compliance director for MedInformatix. Monitor with us™

Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during this episode of Monitor Mondays, when whistleblower attorney Mary Inman reports on an ongoing qui tam action under the federal False Claims Act through which a relator alleges that Bon Secours Health System, Inc. fraudulently billed Medicare and Medicaid millions of dollars. Inman also reports on other current whistleblower cases. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, makes his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, has all the latest developments on the therapy caps as well as the Monitor Mondays Listener Survey. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer continues to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron reports on a recent memo from the U.S. Department of Justice offering good news for some providers. 340B Drug Update: RACmonitor national correspondent Timothy Powell, CPA, reportS on the latest developments regarding the 340B drug discount program. Monitor with us™

On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? Many of these electronic records are self-populated. So, what happens if you undergo a Recovery Audit Contractor (RAC) audit and are accused of wrongdoing? Offering insight into this issue during the next edition of Monitor Mondays will be healthcare attorney Knicole Emanuel, a partner in the Potomac Law Group, who will be the broadcast's special guest. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will be making his Monday Rounds with another installment of his popular segment. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer will continue to report on the vexing issue of Medicare Advantage. Spencer is a senior healthcare consultant for DoctorsManagement. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will report on a recent memo from the U.S. Department of Justice offering good news for some providers. Cyber Report: RACmonitor investigative reporter and New York attorney Edward Roche will report on risks associated with Apple's iPhone's new medical records portal. Roche is the director of scientific intelligence for Barraclough NY LLC. Monitor with us™

Healthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called Star Ratings, which are ultimately published on the Centers for Medicare & Medicaid Services (CMS) website. Explaining the rating systems as well as offering best practices to minimize payer abrasion during this episode of Monitor Mondays is special guest Greg Ford with MRO. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will file another report on the controversial total knee replacement (TKR) issues that continue to confound physicians and patients. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey. Medicare Advantage Report: Monitor Mondays national correspondent J. Paul Spencer will respond to a listener who become ensnared in a Medicare Advantage issue. Spencer is a senior healthcare consultant for DoctorsManagement. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will return with another example of a potentially troublesome issue that could pose a risk to your facility. Prickly Report: Implantable medical device reporting is the prickly subject for the Monitor Mondays Prickly Report. It’s a compliance issue that still confounds providers while at the same time continues to be a hot audit topic for Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing (CERT), and Medicare Administrative Contractors (MACs). Michael Calahan, vice president of hospital and physician compliance with HealthCare Consulting Solutions (HCS), will explain why this issue is low-hanging fruit for auditors. Monitor with us™

“We have been slammed with Medicare Advantage DRG audits,” wrote Sandra from Indiana during last week’s Monitor Mondays broadcast. We asked RACmonitor national correspondent J. Paul Spencer with DoctorsManagement to investigate this issue for this week's episode. Will there be more of these audits? Do these represent low-hanging fruit for auditors? Stay tuned. The episode rundown also includes: Monday Rounds: Ronald Hirsch, MD, vice president of R1 Physician Advisory Services, will file another report on the controversial total knee replacement (TKR) issues that continues to confound physicians and patients. Hot Topics: Monitor Mondays senior correspondent Nancy Beckley, president and CEO for Nancy Beckley and Associates, will have all the latest hot topics and the Monitor Mondays Listener Survey. Healthcare Cyber Report: RACmonitor investigative reporter and New York attorney Edward Roche will return to the broadcast to report shocking examples of cyberattacks on healthcare providers. Roche is the founder and director of scientific intelligence for Barraclough LLC New York. Risky Business: Healthcare attorney David Glaser with Fredrikson & Byron will return after a long absence with another example of a potentially troublesome issue that could pose a risk to your facility. OMHA Report: Prominent healthcare attorney Andrew Wachler, managing partner at Wachler & Associates, will report on the latest offering from the Office of Medicare Hearings and Appeals to expand its current Settlement Conference Facilitation (SCF) program. Monitor with us™

Click here to download this episode Ever think that cash-based practices can only work and be successful in larger metropolitan areas? With lots of wealthy people? Today's interviewee, Brenda Shelton PT, is a great example why that's just not true. She is one of a growing number of successful out-of-network clinics in smaller communities and rural areas, and discusses how referral sources and marketing change when you move from the insurance-based realm into the cash-based model. She's been a PT for nearly 40 years, has had her private-pay practice for 10 years, and plans to treat patients for many years to come because her practice is so enjoyable and accommodating to the life she wants to lead. In this episode, you'll learn about: Her entry into private practice after nearly 30 years in the PT field What skills she has acquired to make her practice successful The characteristics of the people in her small community that make a cash-based practice viable there (hint: it's not wealth. AND she's not the only cash practice in town) How she ended up getting more physician referrals over time even though she struggled to do so when starting out Medicare and her newfound clarity on its regulations and her ability to see beneficiaries An often omitted piece of info for self-claim receipts that will cause reimbursement denials How she utilizes orthotics to add to her revenue and add to the value she can bring to her patients Resources and Links mentioned in this episode: My interview with Nancy Beckley on HIPAA and Medicare regulations My article on Cash Pay PT Receipts and what you need to include on them for self claims The Mulligan Concept – fantastic manual therapy continuing education Click Here to learn how to start your own Cash-Based Practice . Have any questions for Brenda? Don't be shy … drop them in the comments below.

Click here to download this episode This episode is an interview of Nancy Beckley of Nancy Beckley and Associates, a rehab compliance consulting firm. We get into the nitty-gritty of HIPAA (and also Medicare) as it relates to a cash-based practice. She fields my questions for over an hour and absolutely fills us with the info we need to protect ourselves and our practices. In this episode, you'll learn about: What exactly is HIPAA and why does it exist How to determine if your practice is a “Covered Entity” and must comply with all the laws and regulations of HIPAA If you are a covered entity, and what to use an eFax, some important considerations for finding the right HIPAA-compliant system. HIPAA-compliant texting software, and when something like this is necessary if you are texting/emailing about patients with other providers. The HIPAA Omnibus changes and how they may have opened the door (in some scenarios) to provide covered services to a Medicare Beneficiary on a cash-pay basis. The Jimmo vs Sebelius case on “Medical Necessity” and how it affects our ability to see Medicare Beneficiaries on a cash-pay basis for certain types of services. Resources and Links mentioned in this episode: Aaron Lebauer's Guest post at this site on HIPAA and determining your  Practice's Covered Entity Status The HHS Flow Charts and Info Sheet for Determining your Covered Entity Status Attorney (and PT) Specializing in HIPAA: Paul Welk Esq., PT PT specializing in HIPAA Policies and Procedures: Angie Phillips, PT S-Fax My article on the HIPAA law changes and seeing Medicare Beneficiaries on a Cash-Pay Basis. Connect with Nancy at her website: www.nancybeckley.com and at Twitter: @NancyBeckley Click Here to learn how to start your own Cash-Based Practice . Let us know if you enjoyed the show: [Click to Tweet] Thank you @NancyBeckley for being an awesome guest on the Cash-Based Practice Podcast w/ @DrJarodCarter Some parting notes: Definitely have a look at the HHS Info Sheet. As I re-listened to this podcast and reviewed that info sheet, I came across a few things that I wanted to point out or re-highlight: Determining if your practice is a HIPAA Covered Entity comes down to whether or not you transmit any “covered transactions” “in electronic form” “covered transactions” are defined in detail on pages 7 – 9 at the above info sheet. Take a very careful look at all the different things that could be considered covered transactions. It does NOT ONLY include transactions/transmissions of payment/billing-related information. Although I don't directly bill any third-party payers for my services, there are still “covered transactions” that I do occasionally transmit. I therefore have to make sure that I only transmit such things in non-electric format. “In Electric Form” is defined on page 9 of the above info sheet. Essentially, Fax is NOT considered “electronic format” so I, and practices like mine that want to avoid being a “covered entity,” need to make sure that the sending of any information is only done by fax. I'm guessing many of you may have questions for Nancy. Please type them in the comments below, and make sure to give as much detail as possible on all factors and components surrounding your question so she has the best possibility to give a clear answer.

Nancy Beckley is an expert on compliance. She consults around the country and regularly speaks at conference and webinar about compliance issues. In this episode we talk about the components of a compliance program, why every clinic should have a program (whether you take insurance or not), how to start a program, and if a […]