September Monitor Mondays RAC Report Recap

Knicole EmanuelLegal Insights

Monitor Mondays RAC Report Panelist & Practus Healthcare Partner Knicole Emanuel

A Roundup of Monitor Mondays Healthcare Law Updates

RAC Report Panelist & Practus Healthcare Partner Knicole Emanuel

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

Healthcare industry expert and Practus partner, Knicole Emanuel, is a regular contributor to the healthcare industry podcast, Monitor Mondays, by RACmonitor. In this article we break down the important changes that have taken place since the public health emergency (PHE) was declared. 

Featured September RAC Report Summaries

  • ACO Oversight by CMS Questioned by OIG
  • Rate Parity Issues: Telehealth vs Physical Social Adult Day Care
  • Insurance Matters: As a Provider, Are you Covered to Defend Yourself?

Read below to learn more about what you need to know as an industry insider. Be sure to tune into the RAC Report on Monitor Mondays every week as well!

ACO Oversight by CMS Questioned by OIG

Air Date: September 28, 2020

No one is free from audits. Even auditors get audited. However, there are some differences between how the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audits auditors. Though it’s possible healthcare providers can be penalized in the millions for audit issues, the OIG often gives auditors recommendations for changes.

The latest example comes from an OIG audit report from September 2020 of the Accountable Care Organizations (ACOs). For the September 2020 OIG Report, 159 ACOs were required to select a CMS-certified vendor of their choice. Learn more by listening to Knicole Emanuel’s recent webcast: SNFs & COVID-19: New Audits Coming Soon.

The Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) auditors, Unified Program Integrity Contractors (UPICs), and Recovery Audit Contractors (RACs) to audit ACOs. IG report found the following weaknesses in CMS’s supervision of ACOs:

  • CMS did not ensure that its contractor provided feedback reports in time to enable survey vendors to include and evaluate quality assurance plans regarding all of the changes implemented to address issues identified.
  • CMS did not ensure that its contractor reviewed survey instruments translated into other languages.

OIG recommended that CMS increase supervision to confirm changes and collect client feedback. It is my opinion that ACO audits will increase. Comparing this to reports prior to 2019, especially 2017, these findings are in stark contrast. 

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 36: CMS Orders Medicare Advantage Organizations to Cease “Pseudo Denials” to Non-contracted Providers

 

healthcare doctor on tablket device

Rate Parity Issues: Telehealth vs Physical Social Adult Day Care

Air Date: September 21, 2020

Since the public health emergency (PHE) was declared on March 13th, social adult day care facilities have struggled with maintaining care due to telehealth services being requested and matched rate reimbursement unavailable. 

To help ease the financial burden on these facilities, New York Governor Andrew Cuomo declared rate parity reimbursement for adult daycare, whether it was physical or telehealth. However, seven social daycare centers recently approached Ms. Emanuel stating that Managed Care Organizations (MCOs)/MLTCs (Managed Long Term Care) refused equal reimbursement for telehealth services rendered. 

With the PHE still in full swing this translates to a clear violation to Governor Cuomo’s decree. To hear more about the negotiations Knicole Emanuel facilitated to ensure payment was provided to a facility in need, listen to the podcast linked below!

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 35: An Ominous Forecast: Auditors Are Ramping Up Activities

 

Insurance Matters: As a Provider, Are you Covered to Defend Yourself?

Air Date: September 14, 2020

This particular segment focuses on the importance of understanding what coverage is available to health providers in the instance they need to defend themselves against a RAC Audit gone sour. Knicole Emanuel provides a recent example about a client who was a defendant in a fraud case. In this instance,” Dr. X”, a pain management physician, was asked to defend himself when medicare auditors asked to assess his billing practices. In many cases, any insinuation of fraud spooks insurance companies and coverage is revoked. However, he realized his insurance covered up to $25,000 in defense assistance and was able to seek Emanuel’s team for legal counsel. 

While regulations differ for each state’s federal government’s ability to accuse a provider of fraud, insurers bristle at the slightest mention of the word. This can place providers in a difficult and potentially financially damaging position. The moral of this story is understand your policy coverage and be clear on your protections as this scenario is more common than one may think. Listen to the episode linked below to hear Emanuel’s full breakdown of the scenario!

To Listen to the Full Podcast Episode Checkout:

Monitor Mondays | Season 10, Episode 34: The RVU Conundrum: Expect Declines in Operating Income

knicole emanuel partner of practus with blonde hair headshot

About Knicole C. Emanuel, Esq.

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 Monday.

Attorney Phone Email
Knicole Emanuel  (919) 249-9723 Knicole.Emanuel@Practus.com