Monitor Mondays

Compliance: The Underpinnings of ACDIS

The San Diego chapter of the Association of Clinical Documentation Integrity Specialists (ACDIS) is meeting this week in San Diego, attracting a host of well-known CDI subject-matter experts, including James S. Kennedy, MD. and our very own Penny Jefferson, cohost of Talk Ten Tuesdays. Kennedy, a frequent panelist on both Monitor Monday and Talk Ten Tuesday, has agreed to be the latest special guest on the venerated Monitor Mondays Internet broadcast, even after the San Diego ACDIS chapter has gaveled down. Kennedy, purported to be as conversant on ICD-10 coding as most professional coders, will report on the recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit of Medicare Advantage (MA) diagnosis codes from UnitedHealthcare that were submitted to the Centers for Medicare & Medicaid Services (CMS). The long-running Internet broadcast will also include these instantly recognizable segments: • 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 Poyner and Spruill, 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: Adam Brenman, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

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National Case Management Week: The Inside Story of What’s Driving Outcomes

You’re invited to take a journey with us as we spend time walking in the shoes of professional case managers, during National Case Management Week. Join us during the next live edition of the venerated Monitor Monday weekly Internet broadcast. You’ll feel the sense of excitement. The energy is palatable as these care professionals work to improve patient care outcomes and reduce readmissions while helping patients navigate America’s complex healthcare system – thus helping them receive the right care at the right time. The long-running Internet broadcast will also include these instantly recognizable segments: • 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 Poyner and Spruill, 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, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

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DOJ Announces $385 Million Settlement to Resolve False Claims Allegations over Abbott Laboratories Baby Formula

Federal officials announced that a Fortune 500 healthcare devices and medical supplies company has agreed to pay just shy of $385 million to resolve allegations involving issues with its production of baby formula. During the next live edition of the venerable Monitor Mondays weekly broadcast, famed whistleblower attorney Mary Inman, reports on this major false claim act settlement. The long-running Internet broadcast will also include these instantly recognizable segments: • 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: Adam Brenman, senior affairs liaison for Zelis, will report on current healthcare legislation.

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Convicted: The Cases Every Compliance Leader Should Know About Now

Government agencies routinely publicize allegations and settlements. But convictions are different – and far more consequential. When a court reaches such a judgment, the warning is no longer theoretical. Understanding how and why entities or individuals are refunding money or serving prison time as result of valid evidence and the judgment of a court helps give a clearer awareness of regulatory and statutory guardrails. During the next live edition of the venerable Monitor Mondays weekly broadcast, physician and attorney Dr. John K. Hall will examine some recent convictions and help tease out guidance for all of us. The long-running Internet broadcast will also include these instantly recognizable segments: · 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: Matthew Albright, chief legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Complicated Compliance and Auditing That’s More Than Skin Deep

As expected, Monitor Monday continues to focus squarely on healthcare auditing and compliance. During the next live edition of the venerable Internet broadcast, Monitor Monday will examine a range of compliance and auditing concerns associated with skin lacerations. Led by esteemed physician and popular program special guest Dr. James S. Kennedy, the program will take listeners on a fascinating deep dive beneath the skin to explore documentation and reporting issues related to skin laceration repairs. Skin laceration repairs can significantly influence inpatient facility MS-DRG and APR-DRG assignments, depending on the documented depth of the repair: skin only for medical DRGs, or subcutaneous tissue or deeper for surgical DRGs. Dr. Kennedy will discuss differing CPT® and ICD-10-PCS documentation requirements, along with recent CPT Assistant and Coding Clinic guidance affecting skin repair—issues that warrant the attention of facility compliance officers. Broadcast segments will also include these familiar features: Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds. The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Poyner Spruill, will report the latest auditing news. Risky Business: Nicole Moan, Esq., an associate with the law firm of Fredrikson & Byron, will substitute for healthcare attorney David Glaser. Legislative Update: Cate Brantley, JD,senior healthcare legislative affairs analyst for Zelis, will report on current healthcare legislation.

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“Faster than a Speeding Bullet:” The Immediate Compliance Challenge Created by AI

Artificial intelligence (AI) is dramatically reshaping healthcare by accelerating data analysis, auditing, and documentation. But while it appears to reduce provider burden, AI also strengthens medical necessity support. What about compliance – and the role of human oversight? The producers of Monitor Mondays have invited senior compliance consultant Veronica Richardson with First Class Solution to report on current healthcare issues related to these compliance risks, plus essential tips for ensuring that your organization can respond effectively. 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 broadcast with his trademark segment. • False Claims Act Update: Famed whistleblower attorney Mary Inman will report on a recent $541.5 million False Claims Act settlement with The Villages Health System LLC, a Florida provider group, over allegations that it submitted invalid diagnosis codes that increased Medicare Advantage payments – a practice known as risk-adjustment fraud.

Purging the Surge of Data Miners: A New FCA Program from DOJ

There has been a noticeable recent surge of activity among data-mining companies or individuals who analyze publicly available government data for potential signals of fraud, rather than the insiders who have traditionally served as relators under the federal False Claims Act (FCA). As such, the venerable U.S. Department of Justice (DOJ) has a new process in place to mitigate the trend. It’s called Fraud Oversight through Careful Use of Statistics, (FOCUS), which will be the topic of a new report from Mary Inman, who is scheduled to be the special guest on the next edition of Monitor Mondays. 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 broadcast with his trademark segment. • Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Gender Affirming Care (CMS-2451-F): Still Proposed

Program Update: CMS-2451-F has been published in the Federal Register. The proposed rule is effective Oct. 13, 2026. The recently posted rule prohibits federal and state Medicaid and CHIP program dollars from being spent on gender-affirming care for persons under 19 years of age. Earlier this year, CMS-3481-P —a related proposed rule— was reported by Drew Updike, MD, a senior healthcare consultant. That rule was published in mid-December 2025. During the next live edition of the venerable Monitor Monday Internet broadcast, Dr. Updike will share the potential impacts if this proposed rule and CMS 3481-P are both finalized. The broadcast will also include these instantly recognizable segments: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Poyner Spruill, will report the latest news about auditors. • Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment. • Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Buffeted, Badgered, Bruised and Bleeding: The Battered 340B Drug Reforms

Much like the iconic TV commercials in which the late newscaster John Cameron Swayze would demonstrate on live television how the venerable Timex wristwatch could withstand relentless beatings and “could keep on ticking,” the venerable federal drug program, 340B, continues in its role to provide expensive drugs at discounted prices to the nation’s safety-net hospitals. Due to recent legislation introduced in Congress to make comprehensive changes to the federal 340B drug pricing program, the producers of RACmonitor have invited attorney Jeff Davis with the law firm of Bass, Berry & Sim, to summarize key provisions, the potential impact of the legislation on 340B providers and the likelihood of enactment. The broadcast will also include these instantly recognizable segments: • Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will make his Monday Rounds. • The RAC Report: Healthcare attorney Knicole Emanuel, a partner at the law firm of Poyner Spruill, will report the latest news about auditors. • Risky Business: Healthcare attorney David Glaser, a shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment. • Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Latest Privacy Issue: AI-Powered Wearables

You wear a smartwatch as do so many other Americans. In fact, AI is transforming wearable healthcare devices from simple fitness trackers into powerful tools that collect, analyze, and share health information in real time. During the next live edition of the long-running Monitor Monday Internet broadcast, special guest Ray Ribble will take a deep dive into AI-powered wearables and explain what you and your team must do to remain compliant. The broadcast will also include these instantly recognizable segments: • 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, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

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The One Note Samba: DOJ Data Sharing

The Department of Justice (DOJ) recently announced “data sharing” agreements with the Centers for Medicare & Medicaid Services (CMS), the Department of Homeland Security (DHS) and the Federal Trade Commission (FTC). Many believe this latest development might be the most consequential enforcement shift in twenty years. DOJ can now run analytics directly against CMS claims data, DHS travel records, and FTC complaint data, all in one shared environment. During the next live edition of the venerable Monitor Monday Internet broadcast, senior healthcare analyst Frank Cohen, program’s special guest, says it’s the data sharing agreement has changed everything. Register now to listen and learn when Cohen explains why the idea of a defensible pattern just got a lot bigger. It’s important that you need to know what this means for your data. The broadcast will also include these instantly recognizable segments: • 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: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Healthcare Today: Status Quo Bias

Maybe it’s the summer doldrums that keep otherwise rational people from taking a chance—especially when better alternatives may be available. But according to physician and attorney Dr. John K. Hall, the special guest on the next live edition of Monitor Mondays, some individuals prefer to maintain the status quo rather than pursue a potentially better approach. Case in point: Aetna’s recent discharge policy. Beyond the policy itself, which seems to be causing consternation among some hospitals, are there other examples? Listen to the special broadcast Monday, July 27, at 10:00 a.m. EST. The broadcast will also include these instantly recognizable segments: • 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: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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The Latest Compliance Trap: Medicare Cost Reports

Who would have thought that the otherwise fairly simple Medicare Cost Report could be a serious compliance trap? Some are calling the new Medicare report worksheet a possible precursor to the most significant reimbursement change in decades. For 2026, the Centers for Medicare & Medicaid Services (CMS) will require hospitals to report Medicare Advantage (MA)-negotiated reimbursement by Medicare Severity Diagnosis-Related Group (MS-DRG). The implications extend far beyond compliance, requiring coordination across reimbursement, finance, revenue cycle, managed care, coding, IT, and analytics. Listen and learn during the next edition of Monitor Mondays when the CEO for Panacea Healthcare, Kevin Chmura, unpacks Worksheet S-12. You’ll quickly discover the finer details of the looming fundamental shift toward market-based reimbursement, and how forward-thinking hospitals can turn this change into a strategic advantage. 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 broadcast with his trademark segment. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

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Preventing Denials: The Role of Facility-Based Clinical Definitions

Payer-driven clinical validation is a common reason given by payers to remove ICD-10-CM/PCS diagnosis and procedure codes affecting reimbursement or quality-based payment models (e.g., the Centers for Medicare & Medicaid Services/CMS Hospital-Acquired Conditions), even though these codes are based on the documentation of licensed providers. During the next Internet broadcast of the venerable Monitor Monday, Dr. James S. Kennedy of CDIMD will propose a strategy that engages payers in how patient conditions or treatments should be defined, diagnosed, and documented, elevating the practice of medicine and confronting denials that are often based on misinterpretations of current clinical literature. 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 broadcast with his trademark segment. • Legislative Update: Cate Brantley, legislative affairs liaison for Zelis, will report on current healthcare legislation.

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Behavioral Health: Avoiding Common Pitfalls

Behavioral health services continue to face heightened payer scrutiny. The result: inaccurate documentation, coding, and compliance issues. Panacea Healthcare recently hosted a webinar that focused on three high-risk areas: relative to Behavioral Health–telehealth, psychotherapy with evaluation and management (E&M) services, and the Collaborative Care Model (CoCM). Special guest George Kelly is expected to summarize these issues while outlining the common compliance pitfalls, documentation requirements, coding best practices, and audit risks associated with each service. 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 broadcast with his trademark segment. • Legislative Update: Adam Brenman, legislative affairs analyst for Zelis, will report on current healthcare legislation.

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Avoiding the Next Claim Denial

There’s a method by which providers can avoid the snare of the latest claim denial strategy to garner attention. Much has been written about the Aetna policy for its “severity inpatient payment” element. Yet almost daily, providers appear to be turning to trusted sources to avoid pitfalls. And that is why the producers of RACmonitor’s Monitor Mondays have invited physician and attorney Dr. John K. Hall to serve as special guest during the next edition of the venerable weekly national podcast. During this remarkable live Internet broadcast, Dr. Hall will unpack the issues that seem to flummox payers, resulting in a variety of actions, ranging from recoupment to reimbursement at lower levels (i.e. “observation” rates). 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 broadcast with his trademark segment. • Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

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Seeking Compliance Across the Revenue Cycle

Motivated by the notion that healthcare providers are seeking compliance solutions across the revenue cycle, the producers of Monitor Mondays have invited the CEO of Panacea Healthcare Solutions to serve as the special guest during the next upcoming broadcast. Introducing Kevin Chmura. For more than 25 years, Mr. Chmura has been at the forefront of major healthcare vendors as they, in turn, have worked to help their clients achieve success in revenue cycle compliance. 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 broadcast with his trademark segment. • Legislative Update: Cate Brantley, legislative affairs analyst for Zelis, will report on current healthcare legislation.

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Who will Blink First? 340B Health at Center Stage as Controversy Continues

Maureen Testoni, the stalwart president and CEO of the renowned 340B Health Program, will join the long-running Monitor Mondays to discuss Eli Lilly’s escalating demands for hospitals to submit in-house claims data as a condition of receiving 340B drug discounts. Who will blink first? Register now to reserve your participation. 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 broadcast with his trademark segment. · Legislative Update: Folana Houston, legislative affairs analyst for Zelis, will report on current healthcare legislation.

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Recent Lawsuit: Racial Concordance in Healthcare Takes Center Stage

At the heart of a recent lawsuit filed by a physician is whether the medical profession’s understanding and practice of racial concordance is legally defensible. “Find-A-Black-Doctor” has served as a platform for Black, Indigenous, and Persons of Color (BIPOC) to locate providers who can offer them the best holistic treatment. However, some see this as discrimination against white-majority physicians, curtailing their access to potential patients. During my next live edition of Monitor Monday, Dr. Drew Updike, ] review the evidence behind concordance – as it pertains to women’s health, BIPOC patients, and others – to provide you your team with an appreciation of its relevance in modern medicine. 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 broadcast with his trademark segment. • Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.

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AI and Auditing: Major Compliance Risks

It’s that bright new shiny object few seem to manage to resist: artificial intelligence (AI). Here at RACmonitor and Monitor Mondays, we have been reporting on how this disruptive technology has been altering the compliance landscape. And we will continue that reporting. AI is rapidly reshaping healthcare auditing and compliance, and as organizations move toward greater claim visibility and AI-driven review processes, what does that mean for audit exposure, risk, and oversight? Join us during the next live edition of the venerable Monitor Mondays broadcast for an incredible journey, as Pam Warren explores how AI is changing the compliance landscape, and what organizations should be thinking about now. Warren, from AAPC, is the manager of regulatory billing audits for MaineHealth in Maine, the largest healthcare system in Northern New England. 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 broadcast with his trademark segment. · Legislative Update: Cate Brantley, senior legislative affairs liaison for Zelis, will report on current healthcare legislation.

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