Monitor Mondays
Join Chuck Buck every Monday when he welcomes RACmonitor contributing editors and special guests for the latest regulatory audit news and information from CMS, OIG and OMHA. And gain valuable context and perspective that can only be found when you’re listening to the long-running and popular Monitor Mondays. Register to attend live here: https://racmonitor.medlearn.com/racmonitor/podcasts/
Episodes
398 episodes
SCOTUS Decision on Colorado “Conversion Therapy” Ban Leaves Much Left to Determine
The recent U.S. Supreme Court decision in Chiles v. Salazar doesn’t really close the case – but it also doesn’t really leave it open. The 8-1 decision, in which the nation’s highest court ruled that a Colorado ban on so-cal...
A Close-Up Look at Healthcare AI “Sherpas”
Artificial intelligence (AI) is clearly here to stay – it’s now an integral part of healthcare. From coding and clinical validation to payer denials and appeals, AI is often a form of power upon which decisions are made by providers, payers, an...
EXCLUSIVE: Huge Loophole Has Insulated Medicare Appeals
When the U.S. Supreme Court overturned Chevron deference, it promised to restore judicial independence and limit agency overreach. But in Medicare administrative proceedings, that promise remains unfulfilled. Tune in to ...
Medical Double Dose: A Paradox on Doctor’s Day
National Doctor’s Day will bring a double whammy this coming Monday when the venerable Monitor Monday continues its recognition of the occasion with a pair of featured speakers: Drs. Drew Updike and Christopher Boyle.The day of recogniti...
Understanding AI Interpretation in Healthcare
Artificial intelligence (AI) is becoming part of how clinical documentation is reviewed across healthcare, from coding and clinical validation to payer denials and appeals. In many cases, AI is influencing decisions behind the scene...
Aetna Latest to Acquiesce Amid FCA Allegations
Aetna is just the latest in a long list of healthcare entities to settle False Claims Act (FCA) allegations with a massive settlement.The insurer, one of the nation’s largest, recently agreed to pay $117.7 million to resolve a case invo...
Autonomous Coding: A New Reality
Imagine machine learning and natural language processing deployed to audit claims.Today, it’s the new reality.Autonomous coding is dramatically altering the treacherous auditing landscape. So, how can you protect your facility fro...
Lesson Learned: Navigating the Ever-Expanding Scope of Prior Authorization
Healthcare documentation is no longer written for a single audience. Today, the medical record must simultaneously meet federal regulatory requirements and the coverage expectations of individual payers.While these systems often overlap,...
CMS Launches CRUSH: A New Anti-Fraud Program
The Centers for Medicare & Medicaid Services (CMS) has launched a new initiative titled Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH).CRUSH is a sweeping fraud prevention program. In an official news release post...
Medicare Advantage and Prior Authorizations: The Good. The Bad. The Ugly.
Prior authorizations among Medicare Advantage plans have drawn criticism and concern from patients, providers, lawmakers, and regulators. But hospitals and doctors are uniquely positioned to advocate for their patients’ access to and coverage f...
Did CMS Draw the Right Conclusion about Aetna’s Severity Policy?
In a January 28 article, Dr. Ronald Hirsch verified that the Centers for Medicare and Medicaid Services (CMS) “has no problem” with the Aetna Severity Payment policy because it “meets the Two-Midnight Rule.” However, there is more t...
Reign of Terror: Special Audit Report
It’s raining RACs.The Recovery Auditor Contractors (RACs), together with an alphabet soup of other private and public auditors, are coming down hard on hospitals and physician practices, looking for omissions and errors in submitted clai...
Docs Take Another Financial Hit
There was a time when Relative Value Units (RVUs) felt like a stable currency – something you and others could take to the bank. That was then. This is now.Then, productivity could be measured, compensation plans could be man...
$556 million False Claims Settlement Rattles Many in Healthcare
While many of you were enjoying the holidays, Kaiser Permanente wasback in the news. This time, another whistleblower case which resulted inan amazing $556 million settlement to resolve allegations that the giantprovider/payer fudge...
CMS Blocks Gender Affirmative Care
The Centers for Medicare & Medicaid Services (CMS) will block hospitals from performing certain interventions that are intended to change a child’s physical appearance to align an asserted sex identity.Reporting the lead story during...
The Whistleblower Update
Whistleblower attorney Max Volman will return to the next Monitor Monday broadcast to report the latest news about whistleblowers. As we have learned, often “whistleblowers” are not insiders reporting wrongdoing; they tend ...
The Fatal Blow: “Statistically Valid Extrapolation”
For years, federal audit contractors have treated statistical extrapolation as the unassailable engine driving massive overpayment demands. The premise sounds reasonable enough: review a small sample of claims, calculate an error ra...
The Feds Blow the Whistle: A $45 Million Wound Care Settlement
The False Claims Act (FCA) suit was initiated by the U.S. government, not a traditional whistleblower. Nonetheless, the recent $45 million settlement with a Florida physician and his wound care group – Vohra Wound Physicians Management LLC – re...
Providers Appear More Aggressive in Defending Revenue
It’s raining RACs. And many other third party auditors. It seems like every submission of medical records is being scrutinized for omission and commission. Then enter artificial intelligence (AI). The use of AI in auditing, although relat...
New Audit Traps Revealed in the 2026 Medicare Physician Fee Schedule
The Centers for Medicare & Medicaid Services (CMS) recently released the 2026 Medicare Physician Fee Schedule. And while that’s not breaking news, the important news is that you and your team could benefit by understanding its hidden traps ...
New Sepsis Definition Could Help You Achieve Denial Avoidance
Recently, a new version of the Sequential Organ Failure Assessment (SOFA) score was introduced.Known as SOFA-2, this new definition aligns with organ dysfunction measurement in critically ill adults with current clinical practices, espec...
DME Supplier Pays $37 Million to Resolve FCA Allegations
Durable medical equipment (DME) supplier Semler Scientific Inc., along with a former distributor, Bard Peripheral Vascular Inc. and its related companies, have agreed to pay $37 million to resolve allegations that they violated the False Claims...
A New Drug Crisis Soon Facing American Hospitals
America’s hospitals will soon face an unprecedented rebate-based prescription drug model, come Jan. 1 – that’s when there will be as many as 10 major drugs subject to Medicare price caps. This development is expected to create administrative an...
The Lowdown on the Shutdown
This marks the third week of the federal government shutdown: an epic failure of congressional leaders from both political parties who couldn’t agree on how fund the government for the fiscal year that began Oct. 1.And now many experts i...
During Case Management Week: Unpacking Healthcare Cuts
You’re invited to go behind the scenes and listen as case managers tell their stories – of long hours, little sleep, and always being ambushed by a bell ringing for help.These unsung heroes of healthcare are receiving their moment in the...