November Monitor Mondays RAC Report Recap | Knicole Emanuel

Knicole EmanuelLegal Insights

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A Roundup of Healthcare Law Updates on Monitor Mondays

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Healthcare industry expert and Practus partner, Knicole Emanuel, is a regular contributor to the healthcare industry podcast, Monitor Mondays, by RACmonitor

Featured RAC Report Summaries from November

  • Knicole Emanuel Hosts Webcast On PRFs and RAC Audits
  • CMS Announces New Reimbursement Rates For COVID-19 Treatment
  • Compliance and Provider Relief Funds: New Guidance Released
  • Provider Relief Funds: The Hottest RAC Audit Subject
  • The Definition of Medical Necessity in the Era of COVID

Read the summaries below and tune into the RAC Report on Monitor Mondays each week!

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Evaluating Provider Relief Funds for Healthcare Providers

Air Date: November 30, 2020

The last three weeks have had a similar theme around how healthcare providers may avoid trouble when auditors come knocking to evaluate the use of PRFs (provider relief funds). Here are a few things to know about the upcoming audits. 

  1. HHS will require providers to comply with reporting requirements if they received over $10,000 in PRFs. All providers that retained that payment for 90 days without rejecting the funds, are deemed to have accepted the terms and conditions. Even if an attestation was never signed.
  2. There are no appeals or dispute processes for the amount of funds you did or did not receive.
  3. Original documentation will need to be retained for three years after the date of the submission of the final expenditure report. 
  4. Audits will focus on use of funds. With so much gray area here, but it’s important to remember that ignorance of the law is not a defense. Stay on top of the updates as they become available. 
  5. There’s a difference between capital equipment use and capital facility use and both have different rules to abide by.

Knicole Emanuel To Host Webcast On PRFs and RAC Audits

Knicole Emanuel will be hosting an up and coming webcast on January 21st, 2021. The topic will focus on Provider Relief Funds RAC Audit: Guidance to Mitigating Risk and Prepare. It will be an insightful analysis for healthcare providers looking to avoid any of the traps stemming from PRF (Provider Relief Funds) compliance.

For more details about these rules, check out the latest podcast episode. Continue to check back on our webcast page for updates once spots become available for Knicole’s webcast in January 2021. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 45: $6.38 Million Medicare Advantage Whistleblower Settlement


CMS Announces New Reimbursement Rates For COVID-19 Treatment

Air Date: November 23, 2020

Helping us discuss how to avoid typical pitfalls in the RAC audit area is fellow Practus attorney, Ashley Thomson, who filled in for Knicole Emanuel this week.

With the constant changes related to COVID-19 relief, it’s no wonder there’s so much confusion within the healthcare provider community. On November 13th, the Centers for Medicare & Medicaid Services (CMS) announced newly added medical treatments for the COVID-19 vaccines will be reimbursable to healthcare providers in the near future. CMS also stated in a recent announcement that they will be taking action to increase reimbursement for any new COVID-19 treatments that are approved or authorized by the FDA. However, we have not been able to determine a current reimbursement rate at this time. RAC Monitor panelist, Dr. Ronald Hirsch, helped clarify that any new treatment means any new technology or add-on money for any COVID-19 therapy that gets emergency use authorization. As an example, think of the monoclonal antibody.

With these reimbursement rates comes a cap on what they can be applied to. Ensuring that healthcare providers have staff members to help track the dates of new reimbursement rates, ensuring the correct modifier is being used when coding, and tracking any and all reimbursements received to avoid hang ups once auditors come knocking, will be key. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 44: COVID-19: Coronavirus and Compliance A Special 60-Minute Open Door Forum


Compliance and Provider Relief Funds: New Guidance Released

Air Date: November 16, 2020

This episode’s topic revolves around the additional Provider Relief Funds (PRFs) that were made available in phase three. An additional $20 billion has been distributed, the majority going to healthcare providers on the front lines. It was recently announced that providers that have received more than $750,000 from the PRFs are also subject to a single audit, guaranteed. This also applies to almost all non- & for-profit and government providers who received the payment. It’s worth noting that if any of the funds are unused by the deadline, July 31, 2021. Audits will be focusing on the use and acceptance of PRFs and whether the right criteria was met. Below is a brief breakdown of the recommendations for preparing these audits. 

Knicole admits many questions exist for providers that aren’t sure if they still qualify for these PRFs. It’s important for them to know:

  • They must record and report any PRF dollars incurred and used. 
  • If providers accepted any funds during the 2020 calendar year, all revenue for 2019 and 2020 must also be reported, even if the funds were only used for two months out of the year. 
  • Lastly, all recipients of aggregated PRF payments greater than $10,000 must report use of funds before December 31, 2020. Recipients of funds unexpended by this date will have 6 more months to use the remainder of these funds. Afterwards, a second and final report after July 31st is required. 

The moral of the story here is to ensure you are staying PRF compliant and keep listening to hear more about any updates to this relief fund. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 43: Triaging Denials: Emphasize Preparation, Don’t Panic

COVID-19- health check

Provider Relief Funds: The Hottest RAC Audit Subject

Air Date: November 9, 2020

In this episode, Provider Relief Funds are front and center out of the Coronavirus Aid, Relief and Economic Security (CARES) Act. With PRFs being provided via general distribution or targeted distributions, they are suspected to be a hotly contested topic with RACs and MACs for years to come due to the specific compliance requirements. 

Providers must currently follow a  specific two-step process to report the use of PRFs while HHS continues to also add clarification to the FAQs around the parameters. They recently indicated that a revised notice would be posted to remove the “net of the healthcare-related expenses” language in the guidance. We currently do not have guidance regarding when this clarification is to be put into place officially. This is another moving target for auditors.

Some main topics around PRF audits include, how providers applied for the use of the funds, balance billing, or any purchases/transactions that take place with the use of PRFs. How those scenarios will be audited remains to be seen.

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 42: Avoiding a Major Healthcare Crisis: The Need to Bring Back Post-Acute Waivers


The Definition of Medical Necessity in the Era of COVID

Air Date: November 2, 2020

This week’s podcast tackles the ambiguous yet pervasively litigated topic, “medical necessity” and the important role it’s playing as the global pandemic continues to play out. Knicole starts out by briefly laying out an example pertaining to her 96 year old grandmother. Were an auditor audits her grandma’s facility and finds that she does not meet medical necessity – for whatever reason – that would not be fair to her facility. The hope is that her facility is reimbursed for the care they provide. However, sometimes, in an audit, it comes down to the definition of “medical necessity.”

Medical necessity is often based on the eye of the beholder, that to say, it is not necessarily an objective situation in most cases. The differing definitions from both Black’s Law Dictionary and what’s also provided from the AMA only further contribute to the confusion of understanding what the term means. 

With COVID-19 now in the mix, medical situations that may normally be categorized as benign, could actually be exacerbated should the patient contract the disease. It’s also causing organizations like CMS to propose proposed rules aimed at speeding Medicare coverage of certain innovative devices and codifying a definition of what makes an item or service medically “reasonable and necessary” under the Social Security Act 1861(a)(1)(A). The rule, if finalized, would create a new pathway to coverage, called Medicare Coverage of Innovative Technology (MCIT), which would provide nationwide coverage for technologies designated as “breakthrough” by the Food and Drug Administration (FDA). 

Some potentially positive changes due to a terrible global scenario. However, Knicole leaves health providers with the recommendation to ask the question about whether medical necessity exists in their situation. If you receive push back from auditors, they could be wrong. Due to the vagueness of the definition, the outcome could work in their favor should it be justified. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 41: Civil Monetary Penalties for Paying Ransomware Demands


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About Knicole C. Emanuel, Esq.

Weekly Panelist & Practus Partner, Knicole Emanuel, Runs the RAC Report Segment on RAC Monitor’s Monitor Monday Podcast

For more than 20 years, Practus partner Knicole Emanuel has maintained a healthcare litigation practice, concentrating on Medicare and Medicaid litigation, healthcare regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. 

She has successfully obtained federal injunctions in numerous states. This allowed healthcare providers to remain in business despite the state or federal laws allegations of healthcare fraud, abhorrent billings, and data mining. A wealth of knowledge in her industry, Knicole frequently lectures across the country on healthcare law. This includes the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers. Knicole is a member of the RACmonitor editorial board and a popular panelist on the healthcare industry-related podcast, Monitor Mondays.