2018 and Overpayments - 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

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. The Overpayment Rule. The Overpayment Rule, set forth at 42 U.S.C. 7, 2018), reconsideration denied Jan. 29844, 29921 (May 23, 2014).

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. Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs. Background RADV audits are the main tool that CMS uses to correct overpayments made to MAOs.

Overpayments

Overpayments Overpayment Medicare Medicare

CMS Issues Long-Awaited Medicare Advantage RADV Final Rule

Healthcare Law Blog

FEBRUARY 1, 2023

The Final Rule implements the following changes: CMS will extrapolate RADV audit findings beginning with payment year (“PY”) 2018 and will not extrapolate RADV audit findings for PYs 2011 through 2017. One thing that is certain, CMS can expect further challenges to its RADV audit methodology. emphasis added).

Medicare

Medicare Medicare Overpayments Overpayment

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

Health Law Advisor

FEBRUARY 2, 2023

The final rule codifies long-awaited regulations first proposed by CMS in 2018. As stated in the final rule, CMS intends to extrapolate RADV audit findings beginning with payment year (PY) 2018 but will not extrapolate RADV audit findings retroactively for PYs 2011–2017. CMS expects to recover a total of $4.7 This total includes $41.1

Medicare

Medicare Medicare Overpayments Overpayment

What If Costco Designed the Prescription Drugs Sales Model?

Health Populi

JUNE 5, 2022

“Among the 184 most commonly prescribed drugs in Medicare Part D in 2018, 90% could be purchased at Costco for less than $20 for a 30-day supply.” billion more in 2018 for 184 common generic medications compared with prices for the same drugs available to cash-paying Costco members.” They comprise only 3% of all U.S.

Overpayments

Overpayments Overpayment Medicare Medicare

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 At the same time, CMS is implementing changes in how its Risk Adjustment Data Validation (RADV) audits are conducted and how their findings lead to overpayment assessments. million (net) and $4.7

Overpayments

Overpayments Overpayment Medicare Medicare

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

Notable Omissions from Proposed Rule CMS declined to adopt previously proposed amendments to the standard for “identified overpayments” under Medicare Parts A, B, C, and D. The Social Security Act requires “a person” who has received an overpayment to report and return the overpayment no later than 60 days after being “identified.”

Medicare

Medicare Medicare Overpayments Overpayment

Medicare Advantage 2024 Rate Announcement – Further Impacts to Risk Adjustment

Health Care Law Brief

APRIL 3, 2023

The 2024 Risk Model uses diagnoses from 2018 and costs reflected from 2019 as opposed to the 2020 Risk Model that used 2014 diagnoses and 2015 costs. In the Advance Notice, CMS predicted that the changes to the risk scores and HCC updates will help prevent overpayments by improving the accuracy of payments made to MAOs. See 88 Fed.

Medicare

Medicare Medicare Overpayments Overpayment

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. 2018 Medicare Fee-For-Service improper payment rate is lowest since 2010 Significant progress in saving $4.59B in estimated improper payments for the Medicare Fee-For-Service program. percent in 2018. percent in 2018.

Medicare

Medicare Medicare Overpayments Overpayment

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

Healthcare Compliance Blog

APRIL 14, 2022

The OIG audit period was between October 1, 2016, and September 30, 2018. an overpayment), make all reasonable efforts to determine if the skilled level of care is appropriate before submitting a claim to Medicare. To avoid a “reverse false claim” (i.e.,

Medicare

Medicare Medicare Overpayments Overpayment

Weekly Health Care Real Estate Briefing: Hospital Bond Issues Down 57% | CMS Increases Payments to SNFs | New Podcast on Timeshare Arrangements | MN Hospital Deploys 24 Robots

Hall Render

AUGUST 4, 2023

CMS described the increase as a “parity adjustment recalibration,” noting that it had previously overestimated overpayments to nursing homes, which resulted in an unintended reduction in reimbursement in 2023. The hospital was part of a high-profile ASC CON denial in 2018, which it described as a setback for patients.

Hospitals

Hospitals Overpayments Overpayment Nursing Homes

Medicare Advantage RADV Audit Final Rule Challenged in Court

Healthcare Law Blog

SEPTEMBER 28, 2023

Among other changes, this Final Rule will allow CMS to audit a sample of an MA organization’s (“MAO”) diagnoses reported for risk adjustment purposes (from 2018 and later) and then use the audit findings to calculate an extrapolated improper payment amount for the MAO’s contract. Circuit’s reasoning in UnitedHealthcare v. Becerra , 16 F.4th

Medicare

Medicare Medicare Overpayments Overpayment

Avoiding “Gotcha” Moments in Compliance

YouCompli

NOVEMBER 1, 2023

As a result, the department now has to refund several thousand dollars in overpayments and implement a corrective action plan. In 2018, Jay became an adjunct faculty member with the University of Southern California, Gould School of Law, designing and teaching healthcare compliance courses.

Compliance

Compliance US Department of Health and Human Services Compliance Officers 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. Parties in the High-Risk category that reached settlements since on October 1, 2018, or later are listed here.

Fraud

Fraud Compliance Medicare Medicare

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

Hall Render

JUNE 22, 2022

Table B2: Overall Utilization of Home Health Services, CYs 2018-2021. CY 2018 (Simulated). of 30-day periods in 2018 to 7.8% CMS states a temporary adjustment is necessary to offset this overpayment. pandemic levels is the result of several factors, including a significant exacerbation of the home health staffing crisis.

COVID-19

COVID-19 Payment Systems Medicare Medicare

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

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 billion during the pandemic. In New Jersey, a call for experts in the 60-year-old programming language COBOL was issued to “metaphorically” highlight the age of its systems. The U.S.

Medicaid

Medicaid Medicaid Overpayments Overpayment

Health Care Compliance Brief

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

The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule

Trending Sources

CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments

CMS Issues Long-Awaited Medicare Advantage RADV Final Rule

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

What If Costco Designed the Prescription Drugs Sales Model?

Closing Care Gaps Through Prospective Risk Adjustment

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

Medicare Advantage 2024 Rate Announcement – Further Impacts to Risk Adjustment

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

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

Weekly Health Care Real Estate Briefing: Hospital Bond Issues Down 57% | CMS Increases Payments to SNFs | New Podcast on Timeshare Arrangements | MN Hospital Deploys 24 Robots

Medicare Advantage RADV Audit Final Rule Challenged in Court

Avoiding “Gotcha” Moments in Compliance

Part 3: Audit Documentation to Avoid Potential Appeal Consequences

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

Health Provider News

Why Medicaid Programs Need to Update Their Information Systems

Stay Connected