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Monitor Mondays

Auditors Gone Wild: Rampant Fraud Reported with Medicare Advantage

October 04, 2021 Ronald Hirsch, MD | Knicole Emanuel, Esq. | David Glaser Esq. | Ellen Fink Samnick | Day Egusquiza | Edward Roche, PhD, JD Season 11 Episode 472
Monitor Mondays
Auditors Gone Wild: Rampant Fraud Reported with Medicare Advantage
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Monitor Mondays
Auditors Gone Wild: Rampant Fraud Reported with Medicare Advantage
Oct 04, 2021 Season 11 Episode 472
Ronald Hirsch, MD | Knicole Emanuel, Esq. | David Glaser Esq. | Ellen Fink Samnick | Day Egusquiza | Edward Roche, PhD, JD

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

The DOJ even intervened recently in a consolidation of six whistleblower cases against Kaiser Permanente, alleging risk adjustment fraud. Providing context and clarity on this ongoing challenge during the next edition of Monitor Mondays will be Edward C. Roche, director of scientific intelligence for Barraclough New York LLC, who asserts sarsastically, “we have rhesus monkeys auditing people like MDs, who have spent years and years learning how to make medical decisions.”

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

  • Crisis Standards of Care: Day Egusquiza, president of AR Systems, Inc., and a resident of Idaho, will have the latest update on the crisis-of-care rationing unfolding in Idaho, Montana, and Alaska, as the deadly Delta virus is ravaging the country. This is striking primarily the unvaccinated, who are flooding emergency departments, causing hospitals and health systems to buckle under the strain of too few beds and too few physicians.
  • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
  • RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
  • SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
  • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.
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Show Notes

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

The DOJ even intervened recently in a consolidation of six whistleblower cases against Kaiser Permanente, alleging risk adjustment fraud. Providing context and clarity on this ongoing challenge during the next edition of Monitor Mondays will be Edward C. Roche, director of scientific intelligence for Barraclough New York LLC, who asserts sarsastically, “we have rhesus monkeys auditing people like MDs, who have spent years and years learning how to make medical decisions.”

Monitor Mondays will also have the latest national audit news updates from well-respected broadcast consultants, including:

  • Crisis Standards of Care: Day Egusquiza, president of AR Systems, Inc., and a resident of Idaho, will have the latest update on the crisis-of-care rationing unfolding in Idaho, Montana, and Alaska, as the deadly Delta virus is ravaging the country. This is striking primarily the unvaccinated, who are flooding emergency departments, causing hospitals and health systems to buckle under the strain of too few beds and too few physicians.
  • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will return with another installment of his popular segment.
  • RAC Report: Knicole Emanuel, a partner at the law firm of Practus, will file the Monitor Mondays RAC Report.
  • SDoH Report: Ellen Fink-Samnick,anationally recognized expert on the social determinants of health (SDoH), will have the latest news on a trending topic that is attracting significant media attention. Ellen will also conduct the Monitor Mondays Listeners Survey.
  • Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment, reporting on legal implications facing healthcare providers.