CMS used secret shoppers to call phone numbers advertised on television and discovered a lot of incorrect information and attempts by the agents to coerce enrollment.
I am recently back from a visit out west. I want to give a shout-out to the health information management (HIM) professionals who attended the Oregon Health Information Management Association meeting on Saturday in Albany, Oregon and heard me speak. We all had a delightful time. It was especially rewarding when I was approached by an attendee who told me how much they enjoy listening to Monitor Monday, and how useful they find the information.
My objective was to familiarize the attendees with some of the concepts of utilization review (UR), so they can at least have an awareness of the work of their colleagues. During the session I did my best to explain the two-midnight rule in language that would make sense to a non-UR person, but I could still see a slight glaze over their eyes.
On the other hand, when I discussed the games that the Medicare Advantage (MA) plans and commercial insurers play in denying everything possible, they all vigorously nodded, with clear understanding of the issue.
Speaking of MA plans, I know that Monitor Monday and RACmonitor have been talking a lot about them – but so is everyone else. This last week they got more bad news: first, Mayo Clinic in Florida and Arizona has announced that it will not see patients with MA plans for scheduled care. I have heard rumors that there are a lot of old people living in those two states, so that could be a big blow to the MA sales efforts for the thousands of residents who receive world-class medical care at Mayo Clinic.
Second, despite recent rumors of his death, Jimmy “J.J.” Walker is still alive and well, and selling MA plans on television, along with other celebrities such as William Shatner. And it appears that the Centers for Medicare & Medicaid Services (CMS) is not happy about some of those celebrity ads. CMS actually used secret shoppers who called those phone numbers and found a lot of incorrect information, and attempts by the agents to coerce enrollment. They also noted that they “are concerned recent national television advertisements promoting MA plan benefits and cost savings, which may only be available in limited service areas or for limited groups of enrollees, overstate the available benefits, as well as use words and imagery that may confuse beneficiaries or cause them to believe the advertisement is coming directly from the government.”
As it stands now, MA plans must submit their advertisements to CMS for review, and after five days they may begin using the material unless CMS objects under what is called the “File and Use” process. But CMS has announced that starting in 2023, the agency will review all television advertisements used by MA plans for marketing under a 45-day timeframe, increase their oversight of all other advertising, and investigate more complaints by listening to the call recordings to see if misleading information was provided.
Now, just to be fair, many of these misleading practices may be from independent agents, but the buck stops at the top – so the MA plans themselves will face the consequences, and rightly so.
Changing topics to something more clinical, a recent clinical trial was released that may get some attention in the world of pain management. Patients who had a spinal nerve stimulator implanted were randomized to trials of spinal cord burst stimulation or placebo stimulation, and pain relief was equivalent.
While I am sure this will be carefully scrutinized, the possible conclusion is that, as we saw with kyphoplasty in the VERTOS trial, the sham procedure may be as effective as the actual treatment at controlling pain. It will be interesting to see how payers and physicians react to this.
Programming note: Listen to Dr. Ronald Hirsch every Monday when he makes his Monday Round live on Monitor Mondays, 10 Eastern and sponsored by R1_RCM.
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional
In the last six weeks, my colleagues and I have dealt with two situations in which clinics either missed or did not receive the orange
Please log in to your account to comment on this article.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
