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Welcome to the Memorial Day Weekend, and thanks for checking in.

We’re bringing you the news from the past week as well as providing you with a look at the week ahead. In observance of Memorial Day there will be no Monitor Mondays on May 30th but we will return on Monday, June 6, “same time, same station,” as they once said on radio. Our special guest will be Mary Beth Pace, RN, BSN, MBA, ACM, CMAC vice president of care management at Trinity Health. 


Pressure Is Mounting

Earlier this week I received an email from a concerned RACmonitor reader who passed along this news:

“I received an email notification/newsletter today from KEPRO which contained an article by Ferdinand Richards III, MD.  This article discussed the fact that quality care reviews could arise from beneficiary complaints, referrals from subcontractors, or other BFCC-QIO reviews,” she wrote.  “The provider community is aware of this fact. However, I was unaware that if, after Peer Review the review is deemed to have either a ‘Gross & Flagrant determination or a Substantial Number of Substantial Violations, it could be referred to the OIG for sanctions!  I looked at the CMS.GOV link provided and sure enough, the QIO Manual Chapter 9 – Sanction has been updated as of 2/12/16.”

Here is a response from Ronald Hirsch, MD, vice president of Accretive Physician Advisory Services. 

CMS has recently updated the Sanction, EMTALA, Fraud and Abuse Chapter of the QIO Manual and it is clear from the major changes made that CMS is taking seriously the oversight of providers whose quality of care is poor. In addition, they are now considering patterns of poor medical record documentation and premature discharges leading to readmissions as potentially fraudulent activity, subject to sanctioning by the OIG. Prior to this update, a physician who does a poor job of documenting medical necessity for a surgery would risk denial of payment; now they risk a monetary fine or being excluded from Medicare. The stakes are getting higher as the pressure mounts on CMS to reduce improper payments and improve the quality of care to beneficiaries. 

We will be discussing this subject during the next edition of Monitor Monday on June 6, 10 AM ET. 

QIO Study Update 

We’re planning to conduct another QIO study next Wednesday. So, please let me know how the QIO audits have been affecting your organization, especially the types of issues they are reviewing.


Audit Nation: The Documentary, Exposing Investigatory Audits 

Healthcare industry’s first Internet radio documentary to expose the inner workings of investigatory audits is scheduled to air live on Thursday, June 2 at 1:30 p.m. EST. 

The 60-minute broadcast will reveal investigatory audit practices and the consequences of government and private auditing, the risks these audits pose to organizations, and the regulatory implications facilities and providers currently face nationwide. Access to broadcast is complimentary. 

Healthcare statistician Frank Cohen of DoctorsManagement will lead you through the labyrinth of rules that have become to many an undeclared war on America’s physicians. 

Also participating in the documentary will be…

  • Healthcare attorney David Glaser with Fredrickson & Byron, who will speak to the legal risks and challenges that audits present to the healthcare industry. 
  • Ronald Hirsch, M.D., vice president of Accretive Physician Advisory Services, who will talk about investigatory audits from a physician’s point of view while providing a global perspective on the importance of advocacy. 
  • Pat Marion, a principal at Compliance Concepts, Inc. and formerly of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), who will discuss regulatory challenges associated with working through the process once an audit begins. 
  • Sean Weiss with DoctorsManagement, who will report on the hard cost of being unprepared for an audit versus the relatively lesser cost of when facilities and providers are prepared.

This live broadcast is sponsored by DoctorsManagement. Register Here! 

Avoid Being Wrong on Patient Rights

Ronald Hirsch, MD, FACP, CHCQM
Thursday, June 9, 2016
1:30-2:30 p.m. ET

Knowing how and when to use the right Medicare form will help your facility from providing unreimbursed and medically unnecessary care. Register here.

New Strategies That Are Removing Rural Health from Life Support

Janelle Ali-Dinar, PhD
Thursday, June 23, 2016 
1:30-2:30 PM ET

A new future is happening right now in the delivery of care that is making healthier rural communities and creating new strategic pathways and practices for the most vulnerable of America’s healthcare safety nets. Learn how rural hospitals are achieving “thrive-ability.” Register here.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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