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CMS Reminder of Medicare Fraud, Waste and Abuse Vigilance

Innovaare Compliance

On April 15, 2022, the Centers for Medicare & Medicaid Services (CMS) released potential fraud, waste and abuse (FWA) trending data collected from Medicare Advantage Prescription Drug Plans (plan sponsors) for fourth quarter 2021. Three categories of FWA allegations accounted for 78.47

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California Doctor to Pay over $9.48M, Sentenced to Prison, to Settle Fraud Allegations

Med-Net Compliance

California Attorney General Rob Bonta announced a settlement against a Southern California doctor for submitting false claims to Medicare and Medi-Cal between the years of 2011 and 2018 for drugs, procedures, services, and tests that were never administered to patients. In October 2021, the California Department of Justice’s?Division

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Compliance lessons from recent fraud cases

Health Care Performance

A New York ENT physician was convicted of filing false claims with Medicare and Medicaid. The physician submitted claims totaling about $585,000 to Medicare and Medicaid and was paid roughly $191,000. Mole billing fraud scheme totals $4.1 million in fraudulent payments between 2015 and 2021. That is how you collect $4.1

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How Serious are OIG Exclusions? Key Insights into the Fraud Risk Spectrum

Provider Trust

It’s no secret–when fraud enters healthcare, things get risky. But how exactly does the HHS-OIG (Office of Inspector General), the main body responsible for conducting investigations into suspected fraudulent activity, address healthcare fraud and assess future risk of these bad actors? Department of Justice (DOJ), the U.S.

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Will reporting Medical Loss Ratio Constrain payments to Medicare Advantage plans? 

Innovaare Compliance

Medicare Advantage plans (MAO) have been increasingly popular with Medicare eligible beneficiaries enrolling 51% of the eligible population in 2023 taking in $454 billion (or 54%) in Medicare spending. MLR measures the percentage of premium income and Medicare payments a Sponsor pays for medical claims.

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OIG Advisory Opinion Alert: Yet Another Favorable Decision for Medical Device Manufacturers

Healthcare Law Blog

22-05 , relating to subsidization of certain Medicare cost-sharing obligations in the context of a clinical trial involving medical devices (the “Proposed Arrangement”). Like these other AOs, OIG found that while the Proposed Arrangement could generate fraud and abuse risks under both the Federal anti-kickback statute (i.e.,

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You Play a Vital Role in Protecting the Integrity of the U.S. Healthcare System

AIHC

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. To combat fraud and abuse, all levels within a medical practice, hospital or health care organization must know how to protect the organization from engaging in abusive practices and violations of civil or criminal laws.

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