2018, Medicare and Overpayment - Health Care Compliance Brief

CMS Proposes to Amend Overpayment Rule, Remove Potential Overpayment and False Claims Act Liability for Mere Negligence

Healthcare Law Blog

DECEMBER 27, 2022

The Centers for Medicare and Medicaid Services (“CMS”) has issued a proposed rule which would amend the existing regulations for reporting and returning identified overpayments (the “Proposed Rule”). UnitedHealthcare challenged the current Overpayment Rule in litigation. [1] UnitedHealthcare Litigation. The Proposed Rule.

Overpayments

Overpayments Overpayment Medicare Medicare

CMS Issues Long-Awaited Medicare Advantage RADV Final Rule

Healthcare Law Blog

FEBRUARY 1, 2023

On January 30, 2023 , the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). One thing that is certain, CMS can expect further challenges to its RADV audit methodology. 3d 1, 18 n.19

Medicare

Medicare Medicare Overpayment Overpayments

CMS’s Final Rule on Medicare Advantage Risk Adjustment Data Validation

Health Law Advisor

FEBRUARY 2, 2023

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. The final rule codifies long-awaited regulations first proposed by CMS in 2018.

Medicare

Medicare Medicare Overpayment Overpayments

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Bridging Innovation & Patient Care: The Growing Role of AI

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What If Costco Designed the Prescription Drugs Sales Model?

Health Populi

JUNE 5, 2022

In 2006 the Medicare Part D program was implemented, covering older Americans for prescription drugs for the first time. Medicare further drove expansion of generic drug utilization, with co-pays for generics lower for Medicare enrollees than branded drugs. is that 9 in 10 medicines prescribed are generics. healthcare spending.

Overpayment

Overpayment Overpayments Medicare Medicare

The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule

Health Care Law Brief

JUNE 26, 2022

With this denial, the Overpayment Rule remains in full force and effect, and UnitedHealthcare, among other MA plans, must comply or potentially face False Claims Act (FCA) liability. Congress also required CMS to use the “same methodology” to calculate the costliness of insuring a beneficiary in the MA program and in FFS Medicare.

Overpayments

Overpayments Overpayment Medicare Medicare

CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments

Hall Render

FEBRUARY 14, 2023

billion in overpayments from MAOs for payment years 2011 through 2017. billion in overpayments from MAOs for payment years 2011 through 2017. Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs.

Overpayments

Overpayments Overpayment Medicare Medicare

Posthospital SNF Care in Indiana Generally Met Medicare Level-of-Care Requirements

Healthcare Compliance Blog

APRIL 14, 2022

The Office of Inspector General (OIG) released their findings of an audit they conducted to determine if hospital admissions of Indiana skilled nursing facility (SNF) residents who are enrolled in both Medicare and Medicaid (dually eligible beneficiaries) were potentially avoidable, and if level-of-care requirements for Medicare were met.

Medicare

Medicare Medicare Overpayment Overpayments

2024 Final Rule: CMS Announces More Changes to Medicare Advantage but Declines to Reform the “60 Day Rule”

Health Care Law Brief

APRIL 12, 2023

On April 5, the Centers for Medicare & Medicaid Services (“CMS”) released the 2024 Medicare Advantage and Prescription Drug Benefit Programs Final Rule (“Final Rule”), which will be codified at 42 C.F.R. The SRFs include low-income subsidy, dual eligibility (meaning eligible for Medicare and Medicaid) and disability.

Medicare

Medicare Medicare Overpayment Overpayments

Medicare Advantage RADV Audit Final Rule Challenged in Court

Healthcare Law Blog

SEPTEMBER 28, 2023

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. MAOs will be required to remit improper payments identified during RADV audits in a manner specified by CMS.

Medicare

Medicare Medicare Overpayment Overpayments

Closing Care Gaps Through Prospective Risk Adjustment

HIT Consultant

MARCH 20, 2024

The Centers for Medicare and Medicaid Services (CMS) estimated that for payment year 2018 alone , it will recover $428.4 To address these concerns and other matters, CMS announced significant regulatory changes to the Medicare Advantage (MA) program beginning in 2024. million (net) and $4.7

Overpayment

Overpayment Overpayments Medicare Medicare

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010

CMS.gov

NOVEMBER 16, 2018

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Fri, 11/16/2018 - 18:46. Administrator, Centers for Medicare & Medicaid Services. These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred. percent in 2018.

Medicare

Medicare Medicare Overpayment Overpayments

Fraud Indicators and Red Flags

AIHC

FEBRUARY 17, 2025

There are also self-reporting mechanisms in place to report overpayments on the OIG website ( Self-Disclosure ) and Self-Referral Disclosure for voluntary self-reporting of overpayments on the Centers for Medicare and Medicaid Services (CMS) website. The Data Speaks Data gathered in 2018 was a sign of things to come.

Fraud

Fraud Compliance Overpayment Overpayments

Part 3: Audit Documentation to Avoid Potential Appeal Consequences

AIHC

APRIL 5, 2022

If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back. A great free modifier resource to share with you is the CMS Medicare Administrative Contractor (MAC) “WPS” learning center with on-demand training materials.

Fraud

Fraud Medicare Medicare Compliance

Home Health PPS Proposed Rule for CY2023: More Bad News for the Home Health Industry

Hall Render

JUNE 22, 2022

On Friday, June 17, 2022, the Centers for Medicare & Medicaid Services (“CMS”) posted a pre-publication copy of the Calendar Year (“CY”) 2023 Home Health Prospective Payment System Rate Update (“PPS Rule”). Table B2: Overall Utilization of Home Health Services, CYs 2018-2021. CY 2018 (Simulated).

COVID-19

COVID-19 Payment Systems Medicare Medicare

Medicare Advantage 2024 Rate Announcement – Further Impacts to Risk Adjustment

Health Care Law Brief

APRIL 3, 2023

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ( Rate Announcement ). 1395w-23): Medicare Advantage Organizations (MAOs) are paid a base rate by CMS. Risk Adjustment.

Medicare

Medicare Medicare Overpayment Overpayments

Why Medicaid Programs Need to Update Their Information Systems

HIT Consultant

MARCH 1, 2022

In Ohio, unemployment overpayments reached $3.86 Consider more CMS oversight : Between 2008 and 2018, states spent a total of $44.1 Centers for Medicare and Medicaid Services (CMS) reimbursed states $34.3 billion during the pandemic. Following are three suggestions for a way forward for the Medicaid of tomorrow: 1.

Medicaid

Medicaid Medicaid COVID-19 Overpayment

Health Provider News

Hall Render

FEBRUARY 23, 2024

Acquisition of BCBSLA Paused a Second Time It was the biggest health care deal in Louisiana history.

Nursing Homes

Nursing Homes Nurses Hospitals Medicaid

Health Care Compliance Brief

CMS Proposes to Amend Overpayment Rule, Remove Potential Overpayment and False Claims Act Liability for Mere Negligence

CMS Issues Long-Awaited Medicare Advantage RADV Final Rule

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CMS’s Final Rule on Medicare Advantage Risk Adjustment Data Validation

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What If Costco Designed the Prescription Drugs Sales Model?

The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule

CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments

Posthospital SNF Care in Indiana Generally Met Medicare Level-of-Care Requirements

2024 Final Rule: CMS Announces More Changes to Medicare Advantage but Declines to Reform the “60 Day Rule”

Medicare Advantage RADV Audit Final Rule Challenged in Court

Closing Care Gaps Through Prospective Risk Adjustment

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010

Fraud Indicators and Red Flags

Part 3: Audit Documentation to Avoid Potential Appeal Consequences

Home Health PPS Proposed Rule for CY2023: More Bad News for the Home Health Industry

Medicare Advantage 2024 Rate Announcement – Further Impacts to Risk Adjustment

Why Medicaid Programs Need to Update Their Information Systems

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