The Transparency in Coverage (TiC) Final Rule represents one of the most significant regulatory shifts in healthcare pricing since the implementation of the Patient Protection and Affordable Care Act. During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will walk you and your team through the comprehensive labyrinth of changes. Recent enforcement developments, including President Trump’s Executive Order 14221, directing actual hospital price disclosure within 90...
Jun 30, 2025•29 min•Season 14Ep. 641
Call it a trifecta, triumvirate, or the Triple Crown of 2025. “Fraud, waste, and abuse” is the current triple-negative buzzword in America’s lexicon. And it’s being used to describe lots of things. But when that phrase is used by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), what does it actually mean? You’ll learn during the next live edition of Monitor Mondays. That’s when senior healthcare consultant Dr. Drew Updike – the broadcast’s special guest –...
Jun 23, 2025•32 min•Season 14Ep. 640
Clinical denials by payers for sepsis continues. The problem: the definition of the enigmatic condition does not meet their propriety definitions. Enter Dr. James Kennedy, who will be the special guest during the next live edition of the long-running Monitor Mondays broadcast. Dr. Kennedy will report on his recent conversations with the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, in which the agency described its protocols in amending the Index and Tab...
Jun 16, 2025•30 min•Season 14Ep. 639
The nation’s Medicaid program has seen better days. Recently, the federal government’s program to provide healthcare coverage to America’s low-income and vulnerable citizens was used as a bargaining chip as congressional Republicans were in the throes of budget negotiations, facing the daunting task to pass what President Trump calls his “big, beautiful bill:” a package of tax breaks disproportionately favoring the wealthy and spending cuts. The bill, which last week passed in the U.S. House of ...
Jun 09, 2025•31 min•Season 14Ep. 638
During the next edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will provide an update on a whistleblower case that some consider “beyond bad.” You’ll learn why a Texas rheumatologist who was sentenced to 10 years in prison and three years of supervised release was ordered to forfeit more than $28 million, plus 13 real-estate properties, a jet, and a Maserati GranTurismo sports car. Inman, long considered one of the nation’s foremost whistleblow...
Jun 02, 2025•29 min•Season 14Ep. 637
Welcome to a strange new world. Recent tariffs announced by the Trump Administration are likely to impact drug manufacturing, since many drug components are produced outside the U.S., in nations such as in India, giving rise to state laws. Many states limit overseas involvement relative to the Health Insurance Portability and Accountability Act (HIPAA). Florida, for example, prohibits the offshoring of certain patient data, requiring such storage to be within the U.S. Responding to this emerging...
May 19, 2025•30 min•Season 14Ep. 636
On the surface, it was the perfect scam: kickbacks to docs in exchange for public speaking engagements, in order to induce them to prescribe drugs. That’s apparently what Gilead Sciences thought. But a whistleblower blew the whistle, and Gilead admitted to paying hundreds of thousands of dollars to high prescribers of their HIV drugs to serve as speakers at programs at luxury restaurants. Famed whistleblower attorney Mary Inman, partner at Whistleblowers Partners, LLP, will report the savory det...
May 12, 2025•33 min•Season 14Ep. 635
Once again, the venerable 340B Drug Pricing Program finds itself in the crosshairs of critics – this time, from the U.S. Congress. Recently, Sen. Bill Cassidy (R-La.), ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, released a report outlining his office’s investigation into the program. During the next live edition of Monitor Mondays, 340B Health CEO Maureen Testoni will return to the broadcast to offer her response to the senator’s investigation. The long-...
May 05, 2025•28 min•Season 14Ep. 634
Nearly every day, on any news service, images of people being quickly led away is chilling as the current Administration continues its sweep of rounding up and deporting suspected illegal immigrants. Thus, in this current climate of increased audits, investigations and scrutiny on immigration, it is essential that healthcare organizations sponsoring foreign nationals for employment, ensure that documentation, policies, and practices are updated and fully compliant. During the next live edition o...
Apr 28, 2025•30 min•Season 14Ep. 633
The fiscal year (FY) 2026 Inpatient Prospective Payment System (IPPS) proposed rule introduces significant reforms to hospital reimbursement, risk adjustment, and performance measurement. Key changes include the Centers for Medicare & Medicaid Services (CMS) transition to HCC Version 28, the use of the Community Deprivation Index (CDI) for socioeconomic risk adjustment and expanded inclusion of Medicare Advantage data in quality metrics. Launching in 2026, the proposed rule mandates episode-...
Apr 21, 2025•29 min•Season 14Ep. 632
A flurry of national news reports continues to document the large-scale restructuring taking place at the U.S. Department of Health and Human Services (HHS), where 10,000 jobs were reportedly slashed earlier this month, a move also impacting the workforce at the Centers for Medicare & Medicaid Services (CMS). An estimated 300 CMS workers are expected to be affected by this action, while NPR reported that the HHS teams focusing on sexual violence prevention were also eliminated – on the first...
Apr 14, 2025•31 min•Season 14Ep. 631
A recent case, United States v. Junyi Liu, reveals how a $23 million fraud scheme exemplifies vulnerabilities in America’s healthcare system – as you’ll discover when senior healthcare analyst Frank Cohen joins the next Monitor Monday broadcast. You’ll also learn about the challenges legitimate providers face when navigating complex regulations – and more about the government’s aggressive “pay-and-chase” enforcement tactics, plus why innocent practitioners often get caught in the crossfire. Duri...
Apr 07, 2025•31 min•Season 14Ep. 630
No matter the approach one might take for debridement, wound care continues to be an attractive source for audits – they inevitably arise and fester. Case in point: Wachler and Associates, a prestigious law firm in Michigan, currently is representing clients in some 18 wound care audit cases. That is why RACmonitor, producers of Monitor Mondays, has invited Andrew “Drew” Wachler, founder of Wachler & Associates, to be the special guest during the next live edition of the venerable weekly Int...
Mar 31, 2025•30 min•Season 14Ep. 629
National Doctors’ Day is actually Sunday, March 30, but the one-day nationwide observance is getting an early celebratory start during the next live edition of the venerable Monitor Mondays broadcast. Joining our esteemed panelists will be three well-known physicians: Drs. Stephanie Van Zandt, Clarissa Barnes, and Juliet Ugarte Hopkins. And each doc will have an “open mic” during the 30-minute live Internet broadcast. The long-running weekly broadcast will also include these instantly recognizab...
Mar 24, 2025•31 min•Season 14Ep. 628
A clinical documentation integrity (CDI) professional who “knowingly … acts in reckless disregard of the truth or falsity of the information” may ultimately run into issues related to the federal False Claims Act (FCA). The Medicare Fee-for-Service (FFS) Compliance Program on the Centers for Medicare & Medicaid Service (CMS).gov website lists several CMS compliance programs designed to educate and support Medicare providers in “understanding and applying” FFS policies. If the hospital compli...
Mar 17, 2025•30 min•Season 14Ep. 627
Hospitals routinely measure, analyze, and track adverse patient harm events, collecting information about and reporting on certain types of such events in order to meet the Centers for Medicare & Medicaid Services (CMS) program and state legal requirements. Prior work plans of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) revealed that hospitals reported few harm events to state reporting systems. During the next live edition of Monitor Mondays, Dr....
Mar 10, 2025•32 min•Season 14Ep. 626
Across America, in sprawling university teaching facilities and in picturesque rural hospitals, administrators are dealing with a powerful tool called statistical extrapolation. When auditors say that they’re using statistical “sampling” to review your Medicare claims, what they are often doing is using extrapolation – which could take what might appear to be minor discrepancies in your billing and turn them into major financial obligations. To learn more about extrapolation and what it means fo...
Mar 03, 2025•33 min•Season 14Ep. 625
During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medicare home health payment model, Medicare Advantage (MA) claim denials in post-acute care, and increasing threats to Medicaid support. The venerable week...
Feb 24, 2025•30 min•Season 14Ep. 624
Evoking the age-old adage of having “skin in the game,” a Phoenix, Arizona couple last month entered a plea of guilty to one of the largest healthcare frauds in U.S. history. The couple pleaded guilty to criminal charges involving the submission of $1.2 billion in fraudulent claims to Medicare, Medicaid, and other insurers for wound care procedures. The husband-and-wife team have agreed to pay more than $600 million in restitution and face over 20 years in prison, according to famed whistleblowe...
Feb 17, 2025•31 min•Season 14Ep. 623
Challenges in reimbursement, benchmarking, and quality reporting are being experienced in many American hospitals. Why is this problem arising? Our special guest during the next live edition of Monitor Mondays will have answers. Penny Jefferson, a seasoned healthcare professional who serves as the Director of Clinical Documentation Integrity (CDI) Services at the University of California at Davis Medical Center, will report on why misinterpretation of the admission types appears to be the culpri...
Feb 10, 2025•30 min•Season 14Ep. 622
Artificial intelligence (AI) is becoming as commonplace in healthcare as billing audits. It’s ubiquitous. And that is why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to explore the intersection of AI and healthcare. So, during the next live edition of the venerable live weekly Internet broadcast, Cohen will address key concerns for compliance professionals, including Health Insurance Portability and Accountability (HIPAA) requirements, data governance, and...
Feb 03, 2025•28 min•Season 14Ep. 622
Earlier this week, in the wake of the inauguration of President Donald Trump, a major announcement was made that some hope will lead to new advances in healthcare: “Stargate,” a private venture to build in the U.S. hyperscale data centers for artificial intelligence (AI). The strategic goal is to make the United States the world’s leader in AI. Larry Ellison, founder of the relational database company Oracle, indicated that much work in this project will be focused on healthcare, including the p...
Jan 27, 2025•29 min•Season 13Ep. 621
New York health insurer Independent Health and its former executive reached a settlement that will amount to up to $100 million with the U.S. Department of Justice (DOJ) and a whistleblower over False Claims Act allegations that they made Medicare members appear sicker than they really were to get more money from the government, a practice known as risk adjustment fraud. Betsy Gaffney, former CEO of now-defunct vendor DxID, agreed to pay $2 million to resolve allegations she helped DxID mine pat...
Jan 13, 2025•31 min•Season 13Ep. 620
“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling them “Hirsch’s Heroes,” an annual tradition that began in 2015, Hirsch will reveal those to whom he has bestowed the esteemed honor during the next live ...
Dec 16, 2024•29 min•Season 13Ep. 619
Have you ever had your insurance company deny payment for your claim? Have you ever had your insurance company stall or deny a pre-authorization? How long did it take to get the authorization for the medication you’ve been using to keep yourself alive for the past few years? Was it maddening? During the next edition of Monitor Mondays, physician and attorney Dr. John K. Hall will examine the frustration that modern health insurance has become – especially in the context of the recent fatal shoot...
Dec 09, 2024•29 min•Season 13Ep. 618
It’s raining recovery auditors. More denials. More grief. More lost revenue and more palpable anxiety. The seemingly unending war between payers – private and public – and providers continues unabated. The ubiquitous Two-Midnight Rule and the contentious subject of observation versus inpatient status have become an indelible part of America’s healthcare system. And that is why the producers of RACmonitor have dedicated the next live edition of the venerable Monitor Mondays Internet broadcast to ...
Dec 02, 2024•29 min•Season 13Ep. 617
$23 million: that’s the amount that the University of Colorado Health, also known as UCHealth, has agreed to pay to resolve False Claims Act allegations related to its seeking and receiving payment from federal healthcare programs for visits to its emergency departments. The university, headquartered in Aurora, was accused of falsely coding certain Evaluation & Management (E&M) claims submitted to the Medicare and TRICARE programs. Reporting the lede story during the next live edition of...
Nov 25, 2024•22 min•Season 13Ep. 616
As we continue to monitor and review the latest healthcare news, we are always pleased when word of a new study comes to our attention – especially when the study is within the purview of MDaudit. During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report the latest results of a new national study – and how the salient takeaway points could help you and your team as you grapple with the dynamic environment of America’s healthcare system. Broadcast segments w...
Nov 18, 2024•30 min•Season 13Ep. 615
Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements. For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials. During the next live edition of the venerable Internet radio broadcast, Dr. Kartchner will complete his discussion as to how detailed clinical updates, a...
Nov 11, 2024•30 min•Season 13Ep. 614
Denials in healthcare are a problem. Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA). Hut reports that MA plans are classifying hospital stays as outpatient observation visits at a significantly higher rate than traditional Medicare even though the rule is supposed to be applied the same way in both prog...
Nov 04, 2024•29 min•Season 13Ep. 613
