Best RACmonitor Podcasts (2025)

1
The Whistleblower Update 30:37

Play Pause

9d ago30:37

30:37

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 als…

1
The Fatal Blow: “Statistically Valid Extrapolation” 29:25

16d ago29:25

29:25

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 worl…

1
The Feds Blow the Whistle: A $45 Million Wound Care Settlement 31:50

23d ago31:50

31:50

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 lucrati…

1
Providers Appear More Aggressive in Defending Revenue 27:44

30d ago27:44

27:44

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…

1
New Audit Traps Revealed in the 2026 Medicare Physician Fee Schedule 28:24

1M ago28:24

28:24

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 F…

1
New Sepsis Definition Could Help You Achieve Denial Avoidance 30:12

1M ago30:12

30:12

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. 2…

1
DME Supplier Pays $37 Million to Resolve FCA Allegations 30:12

2M ago30:12

30:12

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 pho…

1
A New Drug Crisis Soon Facing American Hospitals 31:09

2M ago31:09

31:09

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 wai…

1
The Lowdown on the Shutdown 28:18

2M ago28:18

28:18

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 …

1
During Case Management Week: Unpacking Healthcare Cuts 59:14

2M ago59:14

59:14

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 …

1
Court Vacates RAVD 2023 Final Rule 29:41

3M ago29:41

29:41

By Frank Cohen, MPA | Adam Brenman | Knicole Emanuel, Esq. | David Glaser, Esq. | Ronald Hirsch FACP

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Into a Rabbit Hole: Medical Loss Ratio Fraud Detected in Managed Care Program 28:55

3M ago28:55

28:55

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 de…

1
Whistleblowers Bring Total Knee Replacement DME to its Knees 28:14

3M ago28:14

28:14

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 Mar…

1
When Whistleblowers Can’t Whistle 29:55

3M ago29:55

29:55

Healthcare compliance just shifted fundamentally. Traditional whistleblowers who needed inside access are being replaced by artificial intelligence (AI)-powered relators who mine public datasets and flag statistical anomalies that could signal fraud. The U.S. Department of Justice (DOJ) logged 979 qui tam cases in 2024, many of which were reportedl…

1
Audit Alert: Who’s Auditing AI? 30:28

4M ago30:28

30:28

Consider this a wake-up call. As artificial intelligence (AI) quietly becomes part of the audit trail, healthcare leaders must ask a new question: who’s reviewing the reviewers? During the next live edition of the venerable Monitor Mondays broadcast, contributing editor Sharon Easterling will break down why auditing AI tools are no longer a tech is…

1
Is the UPIC Fraud Prevention System Broken? 30:29

4M ago30:29

30:29

The Unified Program Integrity Contractors (UPICs) are household names in healthcare compliance. But their track record tells a troubling story, according to senior healthcare analyst Frank Cohen. These Medicare fraud enforcement contractors are using controversial extrapolation techniques that providers successfully challenge over 60 percent of the…

1
A Reign of Terror for Providers 30:02

4M ago30:02

30:02

There just might be a reign of terror being experienced at many of America’s hospitals and health systems. Professionally delivered patient care apparently seems to be getting hijacked by auditors compelled to deny claims of omission. Aided by the Centers for Medicare & Medicaid Services (CMS) and abated by auditors private and public, the lingua f…

1
Invalid Prescriptions Trigger CVS Omnicare Whistleblower Lawsuit 28:21

4M ago28:21

28:21

Although the lawsuit was filed by a pharmacist in New Mexico, a federal judge in New York has ordered CVS Omnicare to pay $949,000 to settle a False Claims Act (FCA) case. According to news sources, the Pharmacy Benefits Manager (PBM) allegedly prescribed drugs to individuals in long-term residential facilities that were not supported by valid pres…

1
340B: Fighting Back Against Big Pharma 28:09

5M ago28:09

28:09

Federal legislation has been introduced that is intended to help the beleaguered 340B Health organization via an effort to ban pharmaceutical companies from restricting access to the drug pricing discount program of the same name, through community and specialty contract pharmacies. Reporting this lead story as well as other updates from Congress a…

1
The Changing Audit Landscape 28:44

5M ago28:44

28:44

The rugged audit landscape has changed – and not for the better. Today, there are more potential pitfalls and traps to capture the unprepared and impact them with huge fines and possible incarceration. In fact, the Centers for Medicare & Medicaid Services (CMS) has erected a legal fortress to protect their audit process. It’s not the same old ballg…

1
An OPPS Oops? 30:00

5M ago30:00

30:00

The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for the 2026 fiscal year has been released. Tucked inside the Proposed Rule from the Centers for Medicare & Medicaid Services (CMS) is the agency’s recommendation to phase out the Inpatient-Only List (IPO) over the course of the next three years. Rep…

1
Medicaid Madness 29:30

5M ago29:30

29:30

It’s a Medicaid Madness mess. For many years, Medicaid has been providing support for America’s most vulnerable populations. But now, Medicaid finds itself as a pawn, being manipulated for political gain between two opposing forces: those who view the program as a means to an end to reduce government spending, and those who hold the opposite point …

1
Chevron Deference: What Difference Has a Year Made? 29:35

6M ago29:35

29:35

Looking back and looking ahead, we must reckon with a major shift in America’s judicial landscape: the elimination of the so-called Chevron Deference. Last year, at about this same time, physician and attorney Dr. John K. Hall was the special guest here on Monitor Mondays, and he began his segment explaining the legal concept. Now, more than a year…

1
Breaking News: A Major Regulatory Shift 28:52

6M ago28:52

28:52

The Transparency in Coverage (TiC) Final Rule represents one of the most significant regulatory shifts in healthcare pricing since the implementation of the Patient Protection and Affordable Care Act. During the next live edition of Monitor Mondays, senior healthcare analyst Frank Cohen will walk you and your team through the comprehensive labyrint…

1
Fraud, Waste, and Abuse: The 2025 Triple Crown 31:52

6M ago31:52

31:52

Call it a trifecta, triumvirate, or the Triple Crown of 2025. “Fraud, waste, and abuse” is the current triple-negative buzzword in America’s lexicon. And it’s being used to describe lots of things. But when that phrase is used by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), what does it actually mean? Yo…

1
Compliance Quicksand: Sepsis 30:15

6M ago30:15

30:15

Clinical denials by payers for sepsis continues. The problem: the definition of the enigmatic condition does not meet their propriety definitions. Enter Dr. James Kennedy, who will be the special guest during the next live edition of the long-running Monitor Mondays broadcast. Dr. Kennedy will report on his recent conversations with the Centers for…

1
Medicaid Madness 31:13

7M ago31:13

31:13

The nation’s Medicaid program has seen better days. Recently, the federal government’s program to provide healthcare coverage to America’s low-income and vulnerable citizens was used as a bargaining chip as congressional Republicans were in the throes of budget negotiations, facing the daunting task to pass what President Trump calls his “big, beau…

1
Whistleblower Update: Rheumatologist Sentenced to Jail, Must Forfeit Maserati and Other Possessions 29:27

7M ago29:27

29:27

During the next edition of Monitor Mondays, famed whistleblower attorney Mary Inman, partner at Whistleblower Law, will provide an update on a whistleblower case that some consider “beyond bad.” You’ll learn why a Texas rheumatologist who was sentenced to 10 years in prison and three years of supervised release was ordered to forfeit more than $28 …

1
Tariffs: The Impact on Drugs 30:00

7M ago30:00

30:00

Welcome to a strange new world. Recent tariffs announced by the Trump Administration are likely to impact drug manufacturing, since many drug components are produced outside the U.S., in nations such as in India, giving rise to state laws. Many states limit overseas involvement relative to the Health Insurance Portability and Accountability Act (HI…

1
Speak No Evil: Asking Docs to Weigh In Became a $202 Million False Claims Act Settlement 33:18

8M ago33:18

33:18

On the surface, it was the perfect scam: kickbacks to docs in exchange for public speaking engagements, in order to induce them to prescribe drugs. That’s apparently what Gilead Sciences thought. But a whistleblower blew the whistle, and Gilead admitted to paying hundreds of thousands of dollars to high prescribers of their HIV drugs to serve as sp…

1
340B In the Crosshairs 28:01

8M ago28:01

28:01

Once again, the venerable 340B Drug Pricing Program finds itself in the crosshairs of critics – this time, from the U.S. Congress. Recently, Sen. Bill Cassidy (R-La.), ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, released a report outlining his office’s investigation into the program. During the next live ed…

1
Audit Alert: Immigration in Healthcare 29:58

8M ago29:58

29:58

Nearly every day, on any news service, images of people being quickly led away is chilling as the current Administration continues its sweep of rounding up and deporting suspected illegal immigrants. Thus, in this current climate of increased audits, investigations and scrutiny on immigration, it is essential that healthcare organizations sponsorin…

1
FY 2026 IPPS: Hospital Strategy for Risk Adjustment, Equity, and Reimbursement 29:20

8M ago29:20

29:20

The fiscal year (FY) 2026 Inpatient Prospective Payment System (IPPS) proposed rule introduces significant reforms to hospital reimbursement, risk adjustment, and performance measurement. Key changes include the Centers for Medicare & Medicaid Services (CMS) transition to HCC Version 28, the use of the Community Deprivation Index (CDI) for socioeco…

1
HHS, CMS Latest Apparent Battlegrounds for Social Wars Being Waged by Trump Administration 30:38

8M ago30:38

30:38

A flurry of national news reports continues to document the large-scale restructuring taking place at the U.S. Department of Health and Human Services (HHS), where 10,000 jobs were reportedly slashed earlier this month, a move also impacting the workforce at the Centers for Medicare & Medicaid Services (CMS). An estimated 300 CMS workers are expect…

1
Caught in the Crossfire: How to Avoid Pay-and-Chase Enforcement Tactics 31:29

9M ago31:29

31:29

A recent case, United States v. Junyi Liu, reveals how a $23 million fraud scheme exemplifies vulnerabilities in America’s healthcare system – as you’ll discover when senior healthcare analyst Frank Cohen joins the next Monitor Monday broadcast. You’ll also learn about the challenges legitimate providers face when navigating complex regulations – a…

1
Wound Care: An Open Source for Audits 29:56

9M ago29:56

29:56

No matter the approach one might take for debridement, wound care continues to be an attractive source for audits – they inevitably arise and fester. Case in point: Wachler and Associates, a prestigious law firm in Michigan, currently is representing clients in some 18 wound care audit cases. That is why RACmonitor, producers of Monitor Mondays, ha…

1
Advanced Beneficiary Notice: A Doctors’ Day Observance 30:41

9M ago30:41

30:41

National Doctors’ Day is actually Sunday, March 30, but the one-day nationwide observance is getting an early celebratory start during the next live edition of the venerable Monitor Mondays broadcast. Joining our esteemed panelists will be three well-known physicians: Drs. Stephanie Van Zandt, Clarissa Barnes, and Juliet Ugarte Hopkins. And each do…

1
At the Intersection of CDI and the False Claims Act 30:15

9M ago30:15

30:15

A clinical documentation integrity (CDI) professional who “knowingly … acts in reckless disregard of the truth or falsity of the information” may ultimately run into issues related to the federal False Claims Act (FCA). The Medicare Fee-for-Service (FFS) Compliance Program on the Centers for Medicare & Medicaid Service (CMS).gov website lists sever…

1
Why Complications are Complicated 31:43

10M ago31:43

31:43

Hospitals routinely measure, analyze, and track adverse patient harm events, collecting information about and reporting on certain types of such events in order to meet the Centers for Medicare & Medicaid Services (CMS) program and state legal requirements. Prior work plans of the U.S. Department of Health and Human Services (HHS) Office of Inspect…

1
DEVELOPING STORY: No Public Comment Allowed for HHS Rulemaking 32:41

10M ago32:41

32:41

Across America, in sprawling university teaching facilities and in picturesque rural hospitals, administrators are dealing with a powerful tool called statistical extrapolation. When auditors say that they’re using statistical “sampling” to review your Medicare claims, what they are often doing is using extrapolation – which could take what might a…

1
Hot Off the Presses: Latest Issues Impacting Medicare Home Health Care, Hospice, and Medicaid Services 29:41

10M ago29:41

29:41

During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medica…

1
1.2 Billion in Fraudulent Claims for Wound Care Procedures 30:37

10M ago30:37

30:37

Evoking the age-old adage of having “skin in the game,” a Phoenix, Arizona couple last month entered a plea of guilty to one of the largest healthcare frauds in U.S. history. The couple pleaded guilty to criminal charges involving the submission of $1.2 billion in fraudulent claims to Medicare, Medicaid, and other insurers for wound care procedures…

1
Major Challenges Facing American Hospitals Explained 29:58

11M ago29:58

29:58

Challenges in reimbursement, benchmarking, and quality reporting are being experienced in many American hospitals. Why is this problem arising? Our special guest during the next live edition of Monitor Mondays will have answers. Penny Jefferson, a seasoned healthcare professional who serves as the Director of Clinical Documentation Integrity (CDI) …

1
Artificial Intelligence and Healthcare: Three Critical Areas You Need to Know About 28:24

11M ago28:24

28:24

Artificial intelligence (AI) is becoming as commonplace in healthcare as billing audits. It’s ubiquitous. And that is why the producers of Monitor Mondays have invited senior healthcare analyst Frank Cohen to explore the intersection of AI and healthcare. So, during the next live edition of the venerable live weekly Internet broadcast, Cohen will a…

1
Stargate Promises New Advancements in Medicine. Compliance Unclear 28:52

11M ago28:52

28:52

Earlier this week, in the wake of the inauguration of President Donald Trump, a major announcement was made that some hope will lead to new advances in healthcare: “Stargate,” a private venture to build in the U.S. hyperscale data centers for artificial intelligence (AI). The strategic goal is to make the United States the world’s leader in AI. Lar…

1
Major False Claims Act Settlement Snags New York’s Independent Health 30:41

11M ago30:41

30:41

New York health insurer Independent Health and its former executive reached a settlement that will amount to up to $100 million with the U.S. Department of Justice (DOJ) and a whistleblower over False Claims Act allegations that they made Medicare members appear sicker than they really were to get more money from the government, a practice known as…

1
May I have the Envelope: 2024 Healthcare Heroes to be Revealed 28:43

1y ago28:43

28:43

“He’s making a list, checking it twice…” With a nod to the legendary Tin Pan Alley composer Haven Gillespie, who penned the lyrics to the iconic holiday song, senior healthcare consultant Ronald Hirsch, MD has been making his own list of healthcare professionals all year, paying close attention to their deeds in the field of healthcare. Calling the…

1
Health Insurers in the Spotlight in the Wake of CEO Slaying 28:41

1y ago28:41

28:41

Have you ever had your insurance company deny payment for your claim? Have you ever had your insurance company stall or deny a pre-authorization? How long did it take to get the authorization for the medication you’ve been using to keep yourself alive for the past few years? Was it maddening? During the next edition of Monitor Mondays, physician an…

1
National Audit News Roundup 28:54

1y ago28:54

28:54

It’s raining recovery auditors. More denials. More grief. More lost revenue and more palpable anxiety. The seemingly unending war between payers – private and public – and providers continues unabated. The ubiquitous Two-Midnight Rule and the contentious subject of observation versus inpatient status have become an indelible part of America’s healt…

1
How E&M Code Misuse Triggered an FCA Settlement 22:23

1y ago22:23

22:23

$23 million: that’s the amount that the University of Colorado Health, also known as UCHealth, has agreed to pay to resolve False Claims Act allegations related to its seeking and receiving payment from federal healthcare programs for visits to its emergency departments. The university, headquartered in Aurora, was accused of falsely coding certain…