Monitor Mondays

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 posted Thursday, CMS reported suspending $5.7 billion in suspected fraudulent Medicare payments, preventing $1.5 billion in DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) billing, revoking more than 5,500 providers’ billing privileges, and denying 122,000 claims that failed medical necessity checks.This latest news, including a nationwide DMEPOS enrollment moratorium and a $259.5 million Medicaid funding deferral, signals a decisive shift toward real-time enforcement.What does CRUSH mean for providers, revenue cycle leaders, and compliance teams?Senior healthcare consultant Penny Jefferson will be the special guest during the next live edition of the long-running news and information national podcast Monitor Mondays. Jefferson, the director of clinical do

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 for care. What’s necessary is the need to understand the rules of the process. And Medicare Advantage plans have many of them.During the next live edition of the venerable Monitor Monday, the Internet broadcast, Richelle Marting, a healthcare attorney, and certified coder, will help you understand when and how Medicare Advantage plans can use prior authorizations for the critical protections you need to know to advocate for patient care.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare

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 to consider than compliance with 42 CFR 412.3. Federal regulations also state Medicare Advantage organizations must comply with Traditional Medicare laws including payment criteria for inpatient admissions at 42 CFR 422.101(b)(2). So the burning question remains: Is CMS disregarding pertinent regulations that could nullify Aetna’s policy?During the next live edition of the venerable Monitor Monday, the Internet broadcast, Cheryl Ericson, senior director of clinical policy and education for the Brundage Group, will address this apparent contradiction.Broadcast segments will also include these instantly recognizable features:·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. ·      The RAC Report: Healthcare attorney Knicole Emanuel, p

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 claims.Then there are seemingly contradictory rules from the Centers for Medicare & Medicaid Services (CMS).It’s little wonder that providers are treading cautiously as they look to thread the needle of compliance.This coming Monday, the venerable Monitor Mondays broadcast will present a cadre of the sharpest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – just here.Broadcast segments will also include these instantly recognizable features:·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. ·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. ·      Risky Business: Healthcare attorney David Glaser,

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 managed, and economic models could assume relative stability in physician work measurement.Recently, actions by the Centers for Medicare & Medicaid Services (CMS) – culminating in the 2026 Physician Fee Schedule – signal a philosophical shift in how physician work is valued, adjusted, and used as a policy lever. The takeaway is not that RVUs are broken; it is that they are no longer designed to be static. For more details on this change, the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to be the special guest during the next live edition of the venerated Internet broadcast, coming up on Monday, Feb. 2.Broadcast segments will also include these instantly recognizable features:·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be maki

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 fudged on its Medicare Advantage risk adjustment.Reporting the lead story during the next live edition of Monitor Mondays willbe Liz Soltan, a New York-based senior associate at WhistleblowerPartners. Soltan is a member of the firm's litigation team who representedDr. James Taylor in his landmark False Claims Act (FCA) case againstKaiser Permanente which resolved allegations of Medicare Advantage riskadjustment fraud. Soltan also works on a major Medicare Advantage riskadjustment fraud case against UnitedHealth Group on behalf ofwhistleblower Benjamin Poehling.Broadcast segments will also include these instantly recognizable features: Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM,will be making his Monday Rounds. The RAC Report: Healthcare attorney Knicole Emanuel

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 next live edition of Monitor Mondays will be independent physician consultant Dr. Drew Updike.More than four weeks since its last news broadcast, Monitor Mondays will return this coming Monday, Jan. 12, with a cadre of the smartest minds in healthcare auditing. You’ll hear auditing news you won’t find anywhere else – except here the RACmonitor.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadca

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 to be outside the offending organization.Register now to listen to Max Voldman’s exclusive report.Broadcast segments will also include these instantly recognizable features:●       Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. ●       The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. ●       Legislative Update: Adam Brenman, legislative affairs analyst for Zelis, will report on the news happening at the intersection of healthcare and congressional action.●       Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

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 rate, and multiply across the entire population to produce a "statistically valid" overpayment figure.In a perfect world, this approach might hold up. But healthcare isn't a perfect world. It's a domain where coding is inherently subjective, documentation varies dramatically by provider, and even seasoned experts routinely disagree on the same chart. In this environment, extrapolation doesn't multiply truth—it amplifies uncertainty. Join us Monday during the long-running Monitor Monday when senior healthcare analyst Frank Cohen returns to the broadcast to debunk long-held beliefs regarding auditing, auditors and extrapolation. Broadcast segments will also include these instantly recognizable features:·      Monday Rounds: Ronald Hirsch, MD, vice president of

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 – resolved allegations that group knowingly submitted claims to Medicare for medically unnecessary yet lucrative surgical procedures, when routine non-surgical wound management had actually been done.  During the next live edition of the long-running Monitor Monday Internet broadcast, famed whistleblower attorney Mary Inman will report the details of the amazing case, as a not-so-subtle reminder that crime doesn’t pay.Broadcast segments will also include these instantly recognizable features:·      Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. ·      The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. ·      Legislative Update: Matthew Albr

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 relatively new, is here to stay.How is your facility faring compared to your peers? More audits? Less auditing? More denied claims? More money being recouped?Now you can see for yourself how you’re doing comparing to others. Thanks to the annual benchmark study performed by MDaudit and shared here on Monitor Monday, you will be able to judge for yourself.During the next live edition of the long-running Internet broadcast, Ritesh Ramesh, CEO for MDaudit, will share the findings of his company’s annual 2025 Benchmark study.Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins,

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 – so you can protect your revenue. During the next live edition of Monitor Monday, senior healthcare analyst Frank Cohen will reveal the latest developments in Medicare audit reforms and statistical extrapolation, including the Medicare Program Integrity Manuel (MPIM) standards, plus how artificial intelligence (AI) is changing audit selection for 2025.You and your team will receive expert analysis and practical guidance, as well as gain a better understanding of the true scope of improper payments.The weekly broadcast will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will repor

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, especially those diagnosed with sepsis.Published in the Journal of the American Medical Association (JAMA) on Oct. 29 and available at  https://jamanetwork.com/journals/jama/fullarticle/2840822, this revised tool updates the original 1996 SOFA score, which had remained unchanged despite evolving treatment modalities and technologies. During the next live edition of Monitor Mondays, Dr. James S. Kennedy will discuss this SOFA-2 revision and its expected impact on clinical validation for sepsis – defined by Sepsis-3 as a life-threatening organ dysfunction caused by a dysregulated host response to infection – and how facility clinical workflows can negotiate denial avoidance with payers with this challenging diagnosis.The weekly broadcast will also include these instantly recognizable

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 Act (FCA) by knowingly causing and conspiring to cause the submission of false claims to Medicare for photoplethysmography tests performed using the FloChec and QuantaFlo devices, in connection with the diagnosis of peripheral arterial disease (PAD), according to a report from the U.S. Department of Justice (DOJ).For analysis and context, Mary Inman, partner in the law firm of Whistleblower Partners, will be the special guest during the next live edition of Monitor Mondays.The weekly broadcast will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about a

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 and financial challenges for hospitals, which will have to pay the commercial price for such drugs while waiting for the rebates.For analysis and context, Maureen Testoni, president and CEO for 340B, will be the special guest during the next live edition of Monitor Monday. She will also review a recent Congressional Budget Office (CBO) report, featured in a recent Senate committee hearing, that includes some misrepresentations about why the 340B program has grown in recent years.As a special bonus, the longtime Internet broadcast produced by RACmonitor, will feature senior healthcare consultant Drew Updike, MD, who will recognize the tireless work being performed by the employees of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) who

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 inside and outside of government believe this could be the longest shut down in history, surpassing the previous recordholder, which occurred, ironically, during the first term of President Donald Trump.Reporting on the nuances of the federal government shutdown during the next edition of Monitor Mondays will be veteran ICD10monitor correspondent Timothy Powell. Powell is a regular panelist on the long-running Talk Ten Tuesdays Internet broadcast. In his day job, Powell, a certified public accountant (CPA), is a healthcare consultant.The weekly broadcast will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm o

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 sun during the next live edition of Monitor Mondays, with a special 60-minute broadcast. The first half of the venerable weekly Internet broadcast will continue to bring you the news and information you’ve come to rely upon.During the second segment, Patti Velky, American Case Management Association’s Board President, will report on the sweeping changes in the newly signed One Big Beautiful Bill Act (OBBBA). The law includes nearly $1 trillion in Medicaid cuts, potentially affecting 12 million people. Changes to state-directed payments and provider taxes could slash hospital funding by $340 billion. With key programs like Disproportionate Share Hospitals (DSHs), telehealth, and Hospital at Home still in limbo, the impact on hospitals, especially in Medicaid expansion and non-

Recently, a federal court vacated the Centers for Medicare & Medicaid Services 2023 Risk Adjustment Data Validation (RADV) Final Rule.This action is reshaping the landscape for Medicare Advantage compliance. The rule had authorized contract-level extrapolation and eliminated the longstanding fee-for-service (FFS) adjuster — two changes that dramatically increased the potential scale of overpayment recoveries.Reporting this developing story during the next live edition of Monitor Monday will be senior healthcare analyst Frank Cohen,The weekly broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legisla

A recent case filed by the U.S. Department of Justice (DOJ) reveals how an insider was able to detect fraud in a large managed care organization (MCO).Although the topic of medical loss ratio (MLR) might be arcane to some, when the subject involves millions of dollars of potential fraud, it quickly becomes a large blip on the government’s fraud detection radar.More on this topic will be reported during the next live edition of Monitor Mondays. That’s when whistleblower attorney Max Voldman returns to the long-running Internet broadcast to report on how a payer, Inland Empire Health Plan, miscalculated its MLR in a scheme to rebate less money to the government than to which it was legally obligated.The weekly broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Ri

Three whistleblowers brought a durable medical equipment (DME) provider to its knees.In two separate cases, the whistleblowers targeted Exactech, a manufacturer of total knee replacement (TKR) systems, resulting in a settlement of $8 million to resolve alleged violations of provisions of the False Claims Act (FCA).Famed whistleblower attorney Mary Inman, partner in the law firm of Whistleblower Partners, LLP, will report the excoriating details of the settlement during the next live edition of Monitor Mondays.The weekly broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Cate Brantley