Best RACmonitor Podcasts (2025)

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

24h 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

8d 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

15d 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

22d 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

29d 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

1M 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

1M 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

2M 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

2M 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

2M 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

2M 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

3M 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

3M 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

3M 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

3M 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

4M 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

4M 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

5M 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

5M 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

5M 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

6M 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…

1
New Healthcare Survey Reveals Need for Continuous Financial Risk Monitoring 29:39

6M ago29:39

29:39

As we continue to monitor and review the latest healthcare news, we are always pleased when word of a new study comes to our attention – especially when the study is within the purview of MDaudit. During the next live edition of Monitor Mondays, the CEO for MDaudit, Ritesh Ramesh, will report the latest results of a new national study – and how the…

1
Simplifying the Two-Midnight Rule: Simple as 1, 2, 3 30:19

6M ago30:19

30:19

Long a contentious edict from the Centers for Medicare & Medicaid Services (CMS), the Medicare Two-Midnight Rule can be simplified into three basic elements. For the first time, Monitor Mondays, along with esteemed physician advisor Benjamin Kartchner, will be outlining them, along with all that’s needed to undo the gordian knot of denials. During …

1
Denials Going from Bad to Worse 28:52

6M ago28:52

28:52

Denials in healthcare are a problem. Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA). Hut reports that MA plans are classifying hospital stays as outpatien…

1
Sex, Lies and Turmoil 27:30

7M ago27:30

27:30

A pediatrician under investigation related to accusations that she had engaged in sexual relations with a male patient, having lied about it when applying for another healthcare position, was recently sentenced for making false statements. In another case, a federal contractor agreed to resolve False Claims Act allegations in connection with a gove…

1
The Two-Midnight Rule: Presumption of Risk 26:48

7M ago26:48

26:48

Could you and your care team be at risk when you upgrade a patient from observation to inpatient simply because the patient passed a second midnight in the hospital, based on the Centers for Medicare & Medicaid Services (CMS) contentious Two-Midnight Rule? And what about the expectation? How does expectation enter this equation? And finally, what s…

1
False Claims Act Violation: Unnecessary Drug Testing Flags Feds 26:56

7M ago26:56

26:56

The U.S. Department of Justice (DOJ) has reported that one of America’s largest urine drug-testing companies has agreed to pay $27 million to resolve allegations of unnecessary drug testing and illegal remuneration to physicians. The False Claims Act allegations resolved by this settlement were originally brought in three lawsuits filed by whistleb…

1
340B Drug Rebates: Old Debate Revived, But Shot Down 27:58

7M ago27:58

27:58

A major drug company’s attempt to turn 340B drug pricing program discounts into rebates made big headlines in recent weeks. Maureen Testoni, president and CEO of 340B Health, will review how this potentially major upheaval came about, how 340B stakeholders responded, and how the drugmaker backed off after the federal government threatened it with m…

1
Violence in America’s Hospitals 28:04

8M ago28:04

28:04

As violent crime has trended slightly downward throughout the United States over the last year, a wound to this country’s collective psyche that appears reluctant to close is workplace violence in America’s hospitals. Reporting the lead story during the next live edition of Monitor Mondays will be special assignment contributor Dennis Jones, senior…

1
Whistleblower Report: Oak Street Health Agrees to Pay $60M to Resolve Alleged False Claims Act Liability in Medicare Advantage Patient Recruitment Scheme 28:41

8M ago28:41

28:41

Oak Street Health, headquartered in Chicago and a wholly-owned subsidiary of CVS Health since 2023, has agreed to pay $60 million to resolve allegations that it violated the False Claims Act by paying kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street Health’s primary care clinics, according to a news release…

1
Exposing Challenges to Getting Paid by Medicare Advantage 29:00

8M ago29:00

29:00

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays. Pace, in making the statement, was referring to rules and…

1
How to Ensure Correct Inpatient Status 30:12

8M ago30:12

30:12

What’s wrong with this picture? With more than 10 years of the Centers for Medicare & Medicaid Services (CMS) Two-midnight Rule now behind us, one would presume that most healthcare professionals should know what determines an inpatient status. But some don’t. That is why RACmonitor has invited renowned physician and attorney Dr. John K. Hall to re…

1
New Study Reveals America’s Big Hang-up with Healthcare 28:58

9M ago28:58

28:58

A comprehensive new survey featuring responses from more than 1,500 U.S. patients reveals that they are not only frustrated by poor provider support, but also are experiencing tangible health setbacks – especially when waiting to refill prescriptions and being placed on hold while waiting to speak to a caregiver. Israel Krush, CEO and Co-Founder of…

1
Federal Officials Announce Medical Relief in Wake of Hurricane 27:15

9M ago27:15

27:15

In response to the devastation caused by Hurricane Debby, now Tropical Storm Debby, the Centers for Medicare & Medicaid Services (CMS) has announced additional resources and flexibilities to support the affected states of Florida, Georgia, and South Carolina. Following President Biden’s emergency declarations and U.S. Department of Health and Human…

1
There’s a New Sheriff in Town: New DOJ Program Intends to Snare Even More FCA Fraudsters 28:37

9M ago28:37

28:37

The U.S. Department of Justice (DOJ) has a new whistleblower reward initiative called the DOJ Corporate Whistleblower Awards Pilot Program. The Program, which seeks to fill gaps left by existing whistleblower reward programs, incentivizes whistleblowers to bring tips to the DOJ about types of healthcare fraud not already covered by the False Claims…

1
FY 2025 IPPS: The Clinical Report 31:07

9M ago31:07

31:07

The Inpatient Prospective Payment System Final Rule for Acute Care and Long-Term Care hospitals in the 2025 fiscal year (FY) continues to generate interest from providers, payers, hospital administrators, vendors, and consultants. But what are the significant takeaways for stakeholders as they prepare for the government’s fiscal year, which begins …

1
“Do the Crime, Pay the Fine:” DaVita to Pay$34 million to Resolve Allegations of Illegal Kickbacks 27:28

10M ago27:28

27:28

Denver-based DaVita Inc. has agreed to pay slightly more than $34 million to resolve allegations that it violated the False Claims Act (FCA). The U.S. Department of Justice (DOJ) reported in a news release that DaVita paid kickbacks to induce referrals to DaVita Rx, a former subsidiary that provided pharmacy services for dialysis patients, directin…

1
End of the Road for the ALJs? 30:07

10M ago30:07

30:07

Could the end be near for the administrative law judges of the Centers for Medicare & Medicaid Service (CMS). What about the Office of Medicare Hearings and Appeals (OMHA)? Could these entities be gone from the audit landscape? Case in point: the Supreme Court (SCOTUS) continues eviscerating executive powers. This time SCOTUS has limited the author…

1
Handle with Care: Taking Steps for Safe Transitions 29:12

10M ago29:12

29:12

Have you ever wondered how professional movers carefully pack everything? From expensive china to precious crystal stemware, they seem to have a knack and knowledge for how to prepare. When it comes to healthcare, how safe is the transition from hospital to home if a patient cannot get the services they need at home when they are ready to transitio…

1
No More Chevron? What Happens Next? 29:25

10M ago29:25

29:25

For nearly four decades, a judicial principle known as “Chevron deference” has guided the federal courts as they reviewed litigation associated with federal agencies. Chevron deference allowed legislators to leave statutes somewhat vague, assuming that an agency full of government experts would sort out the details and promulgate effective regulati…

1
Special Alert: DOJ Cracks Down on Nearly 200 Involved in Major Healthcare Fraud Schemes 28:55

11M ago28:55

28:55

In a late-breaking press release, the U.S. Department of Justice (DOJ) announced late Thursday that the agency had charged nearly 200 individuals accused with involvement in various healthcare fraud schemes estimated at $2.7 billion. Charges were brought against nurses, physicians, and others in a national sweep, and it was estimated that more than…

1
How a Different Type of Whistleblower Created a Lesson Worth Learning 28:57

11M ago28:57

28:57

A recent federal court decision in New Jersey demonstrates the viability of a different kind of whistleblower – in this case, a privately defrauded party. The most common type of a whistleblower under the False Claims Act (FCA) tends to be a corporate insider who sees fraud committed against the government by their employer or a company they work w…

1
The Human Touch at the Intersection of Artificial Intelligence and Denied Claims 28:50

11M ago28:50

28:50

Artificial intelligence (AI) is fast becoming a fixture in healthcare revenue cycle management (RCM), where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision. During the next live edition of …

1
OIG On the Prowl: Semi-Annual Report to Congress 31:15

11M ago31:15

31:15

They’re looking for fraudsters, going on the prowl for bad actors, as revealed in the latest semi-annual report to Congress compiled by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In this latest report, the government watchdog identified more than $2.76 billion in expected recoveries and receivables. Pr…

1
Jail Time, or Hefty Fine? 28:40

11M ago28:40

28:40

Most healthcare investigations by the U.S. Department of Justice (DOJ) result in settlements. Many times, the complete details of the settlements in underlying government cases are not fully disclosed. But sometimes, a provider ends up at trial. And when that happens, it often offers insights into what it takes to get hit with hefty fines – and pos…

1
New Medical Technologies: Are They Audit-Proof? 27:01

12M ago27:01

27:01

A deep dive into microbiology can reveal an up-close look at the cells that make up organs of the human body – and corresponding cancer treatments that leave no trace of damage. The science of medicine appears to be moving at the speed of light lately. But will new healthcare technologies be audit-proof? Monitoring these escalating changes and thei…

1
Healthcare Whistleblower Roundup: Recent Settlements Reach Nearly $10 Million 28:21

1y ago28:21

28:21

Two recent settlements to resolve allegations of violating the False Claims Act – both involving the virulent COVID-19 – are the latest in a series of actions that will be reported on during the next edition of Monitor Mondays by famed whistleblower Mary Inman, who also notes that her company, Whistleblower Partners, LLP, is poised to announce anot…

1
The AI Arms Race in Healthcare Auditing: Handicapping Winners and Losers 29:07

1y ago29:07

29:07

The arms race is heating up. On one side there are healthcare providers, and on the opposing side, an army operated by the auditors. Who will be the winners and losers? Are you safe? And how do you protect your facility from claim denials and takebacks, especially when auditors are using artificial intelligence (AI)? RACmonitor investigative report…

1
The Value of Peer-to-Peer Discussion 28:09

1y ago28:09

28:09

Do you have peer-to-peer (P2P) discussions? Are they useful? Are they valuable? And how do you know? Our own physician and attorney, Dr. John K. Hall, will offer his unique take on the value of P2P interactions and how you should measure it during his appearance as Guest Panelist on the next upcoming edition of Monitor Mondays. Broadcast segments w…

1
The Two-Midnight Rule: Navigating Treacherous Medicare Currents 27:49

1y ago27:49

27:49

Like seasoned harbor pilots navigating tugboats through natural and manmade hazards, physician advisors each day face the daunting task of guiding their hospitals through a labyrinth of Medicare rules and regulations. Reporting on those conditions during the next edition of Monitor Mondays will be the vice chair of the recently concluded national c…

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