Monitor Mondays Podcasts

Coming up on: February 21, 2018

Time to Junk the Peer-to-Peer Process?

“The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians,” reports Juliet Ugarte Hopkins, MD, a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. “These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient.”

Should total knee replacements (TKRs) be performed as inpatient or outpatient procedures? Some facilities are admitting all of them as inpatient while other facilities take a more conservative approach to admission. How are TKRs being handled at your facility?

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Who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? We will continue with the second part of this developing story during the next edition of Monitor Mondays, when whistleblower attorney Mary Inman will report on an ongoing qui tam action under the federal False Claims Act through which a relator alleges that Bon Secours Health System, Inc. fraudulently billed Medicare and Medicaid millions of dollars. Inman is also expected to report on other current whistleblower cases.

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On the rugged regulatory terrain, you might confront this issue: who bears the burden and blame of regulatory noncompliance when your facility relies on non-medical software companies that create electronic medical records? 

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Healthcare Effectiveness Data and Information Set (HEDIS) reviews, underway right now by commercial health plans and government payers, are expected to continue through mid-May. Also expected at that time is a massive number of medical record requests from payers as they seek to improve their Medicare Advantage plan quality measurements, called Star Ratings, which are ultimately published on the Centers for Medicare & Medicaid Services (CMS) website. Explaining the rating systems as well as offering best practices to minimize payer abrasion during the next edition of Monitor Mondays will be special guest Greg Ford with MRO.

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