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. 29 and available at https://jamanetwork.com/journals/jama/fullarticle/2840822, this revised tool updates the original 1996 SOFA score, which h...

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 photoplethysmography tests performed using the FloChec and QuantaFlo devices, in connection with the diagnosis of peripheral arterial disease (PAD), a...

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 waiting for the rebates. For analysis and context, Maureen Testoni, president and CEO for 340B, will be the special guest during the next live edition...

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 recordholder, which occurred, ironically, during the first term of President Donald Trump. Reporting on the nuances of the federal government shutd...

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 venerable weekly Internet broadcast will continue to bring you the news and information you’ve come to rely upon. During the second segment, Patti ...

Recently, a federal court vacated the Centers for Medicare & Medicaid Services 2023 Risk Adjustment Data Validation (RADV) Final Rule. This action is reshaping the landscape for Medicare Advantage compliance. The rule had authorized contract-level extrapolation and eliminated the longstanding fee-for-service (FFS) adjuster — two changes that dramatically increased the potential scale of overpayment recoveries. Reporting this developing story during the next live edition of Monitor Monday ...

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 detection radar. More on this topic will be reported during the next live edition of Monitor Mondays. That’s when whistleblower attorney Max Voldman ...

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 Mary Inman, partner in the law firm of Whistleblower Partners, LLP, will report the excoriating details of the settlement during the next live editio...

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 reportedly triggered by mathematical outliers, rather than insider tips. Government agencies, such as the Centers for Medicare & Medicaid Services (CMS)...

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 issue – they’re a documentation integrity and compliance priority. Although this is an important topic for all healthcare professionals, register now...

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 time on appeal. Cohen, who will be the special guest during the next live edition of Monitor Mondays, said he will examine how the 2016 consolidat...

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 franca appears be an entanglement of descriptors, namely “inpatient versus outpatient.” During the next live edition of the venerated Monitor Mo...

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 prescriptions and then submitted claims for reimbursement for those prescriptions to Medicare, Medicaid, and TRICARE. Although a jury trial was held la...

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 and the Trump Administration during the next live edition of Monitor Mondays will be Maureen Testoni, CEO for 340B Health and a frequent guest on th...

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 ballgame – it’s a new one, with lots of new players. It’s also why the producers of Monitor Mondays have invited senior healthcare analyst Frank Coh...

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. Reporting the lead story on this development during the next edition of Monitor Mondays will be longtime panelist Ronald Hirsch, MD. The weekly br...

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 of view. Who will be the winners and losers? During the next live edition of the venerated Monitor Mondays, senior healthcare consultant Dennis Jon...

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 after the U.S. Supreme Court’s landmark decision overturning 40 years of judicial precedent and upending statutory construction and enforcement, w...

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 labyrinth of changes. Recent enforcement developments, including President Trump’s Executive Order 14221, directing actual hospital price disclosure within...

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? You’ll learn during the next live edition of Monitor Mondays. That’s when senior healthcare consultant Dr. Drew Updike – the broadcast’s special gues...