Innovaare Compliance

FEBRUARY 25, 2024

The Centers for Medicare & Medicaid Services (CMS) uses the Hierarchical Condition Category (CMS-HCC) medicare risk adjustment model to determine monthly capitation fees for Medicare Advantage (MA) plans. CMS proposes calibrating the RxHCC model for CY 2025 on 2021 diagnoses and 2022 expenditure data from PDE records.

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MedTrainer

NOVEMBER 17, 2023

This model involves specific regulations and agreements with Medicare and Medicaid, impacting how healthcare providers in the state bill for services and receive payments. Regulations Unique to Maryland To meet the standards of healthcare compliance in Maryland, there are a few additional regulations.

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Compliance Licensing Hospitals Health Insurance 52

Compliancy Group

NOVEMBER 16, 2022

In 2015, legislation known as the Medicare Access and CHIP Reauthorization Act (MACRA) was enacted. Under MACRA, the Centers for Medicare and Medicaid Services created regulations for healthcare providers’ use of health information technology. MACRA MIPS 2022 is discussed in greater detail below. Find Out More!

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Medicare Medicare HIPAA Medicaid 52

Med-Net Compliance

OCTOBER 21, 2022

The Office of Inspector General (OIG) has recently posted the False Claims Act (FCA) settlements for FY 2022 Q1–Q4 on the risk spectrum. OIG cases against these parties are closed without evaluating the effectiveness of any efforts the parties have made to ensure future compliance with Federal healthcare program requirements.

Fraud 59

Fraud Compliance Medicare Medicare 59

Healthcare Law Blog

OCTOBER 27, 2022

On October 21, 2022, the Centers for Medicare and Medicaid Services (CMS) announced changes to its Special Focus Facility (SFF) program, including new steps to address nursing home facilities that fail to graduate from the SFF program in a timely manner, or “yo-yo” back into non-compliance after graduating from the SFF program.

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Nursing Homes Medicaid Medicaid Nurses 96

Health Care Law Brief

FEBRUARY 2, 2024

While still subject to legislative approval, the Executive Budget incorporates the recently approved amendment (“Waiver Amendment”) to New York’s Medicaid Section 1115 Demonstration that includes $7.5 billion in Medicaid investments over the next three years. Services will be delivered via a two-tiered system.

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Medicaid Medicaid Medicare Medicare 52

Innovaare Compliance

FEBRUARY 19, 2024

On January 31, 2024, the Centers for Medicare & Medicaid Services (CMS) released a draft of the 2025 Advance Notice describing the Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ahead of the final notice to be published on April 1, 2024.

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Medicare Medicare Medicaid Medicaid 52

Innovaare Compliance

FEBRUARY 19, 2024

On January 31, 2024, the Centers for Medicare & Medicaid Services (CMS) released a draft of the 2025 Advance Notice describing the Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ahead of the final notice to be published on April 1, 2024.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Innovaare Compliance

APRIL 29, 2022

The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of program audits in February 2022. Multiple Medicare Advantage Prescription Drug Plans (MAPDs) have already received notification of their selection. Medicare Beneficiary Identifier (MBI) has been replaced with Enrollee ID.

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Regulatory Compliance Compliance Medicare Medicare 52

Innovaare Compliance

DECEMBER 25, 2023

Summary of the HPMS Memo Generated by USHER (Inovaare’s AI-powered Compliance Assistant) The Centers for Medicare and Medicaid Services (CMS) issued a memorandum detailing several announcements relating to its 2024 CMS program audit. Make use of resources available on the ( [link] ) to prepare for 2024 program audits.

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Medicare Medicare Medicaid Medicaid 52

Healthcare Blog

AUGUST 23, 2023

It is critical for an organization to have strategies for promoting ethical behavior in healthcare compliance. Strategies Healthcare Organizations Can Use to Promote Ethical Behavior in Compliance Ensuring ethical practices in healthcare compliance is essential to corporate health and the integrity of your organization.

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Compliance Nurses Regulatory Compliance Medicaid 56

Healthcare IT Today

JANUARY 2, 2024

In healthcare, unauthorized access translates to compliance failures, potential lawsuits, additional financial losses, and even weakened brand reputation and loss of customer trust. In 2022, DigiCert found that 47% of consumers stopped doing business with an organization once trust was lost in the organization’s digital security.

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Compliance US Department of Health and Human Services HIPAA Health Insurance 69

YouCompli

FEBRUARY 22, 2023

Raising prices on your hospital’s chargemaster can also raise your level of compliance grief. Most federal healthcare payors such as Medicare and Medicaid reimburse most providers on a prospective basis. The CCR is determined by a hospital’s cost report that is reconciled with the local Medicare contractor.

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Compliance US Department of Health and Human Services Overpayments Overpayment 52

MRO Compliance

JUNE 1, 2022

Each year HEDIS rating criteria is updated, meaning your organization needs to stay up-to-date on the latest news and trends for HEDIS compliance audits. HEDIS (Healthcare Effectiveness and Data Information Set) is part of a review process for Medicare Advantage plan quality measures. Compliance with HEDIS specifications.

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Medicare Medicare Compliance Medicaid 130

Medisys Compliance

MAY 19, 2022

The federal government, state Medicaid programs, and private insurers have expanded coverage for virtual health care services. During the COVID-19 public health emergency, any health care provider who is eligible to bill Medicare can bill for telehealth services regardless of where the patient or provider is located. Eligible services.

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COVID-19 Medicare Medicare Medical Billing 52

Medval Compliance Blog

FEBRUARY 8, 2022

The Centers for Medicare & Medicaid Services (CMS) announced yesterday that it will be hosting a Workers’ Compensation Medicare Set-Aside (WCMSA) webinar next Thursday, February 17, 2022 at 1:00 pm ET. The post CMS to Host Workers’ Compensation Medicare Set-Aside Webinar appeared first on Medval.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Healthcare Compliance Blog

MARCH 2, 2022

An indictment was filed on February 25, 2022, against ten persons in Florida for their alleged roles in a $67 million healthcare fraud, wire fraud kickback, and money laundering scheme. The ten Florida defendants began their initial appearances in federal court during the last week of February 2022.

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Medicare Medicare Fraud Compliance 45

Innovaare Compliance

JUNE 21, 2023

The Inflation Reduction Act of 2022 has wide-ranging impact on payments for drugs used by Medicare beneficiaries, whether they are administered in the provider’s office (Part B) or used in the ambulatory setting (Part D). Part B drugs have had the fastest spending growth for drugs for Medicare. percent annually.

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US Department of Health and Human Services Medicare Medicare Medicaid 52

Provider Trust

JANUARY 25, 2024

Ensuring the Financial Integrity of HHS Programs In fiscal year (FY) 2022, improper payments within healthcare programs like Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) were estimated at a staggering $131.6 With Medicaid, the challenges are equally formidable.

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Fraud Medicaid Medicaid Medicare 52

Bill of Health

DECEMBER 6, 2023

To assess the prevalence of ghost networks, Senate Finance Committee staffers conducted a secret shopper study of 120 mental health provider listings across 12 Medicare Advantage plans. The Consolidated Appropriations Act of 2023 requires Medicaid plans to publish and update accurate and searchable provider directories.

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Governance Medicaid Medicaid Medicare 144

Verisys

DECEMBER 22, 2021

However, based on discussions with Verisys clients and prospects, most health plans are unprepared to meet the requirements due by January 1, 2022. Should a group health plan, insurer, or state agency find that time is running out on achieving regulatory compliance with H.R. The post Ensuring Provider Directory Compliance With H.R.

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Compliance Regulatory Compliance Healthcare information Technology Health Insurance 52

American Medical Compliance

AUGUST 1, 2022

In Spring 2022’s Semiannual Report to Congress (SAR), the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) reported that nearly $3 billion had been misspent on Medicare and Medicaid services. This includes recommending compliance programs or trainings for staff. Get Certified.

US Department of Health and Human Services 52

US Department of Health and Human Services Nursing Homes COVID-19 Medicare 52

Innovaare Compliance

JUNE 28, 2022

The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of CMS program audits in February 2022. Even though we’re six weeks from the end of the 2022 cycle, there’s still time to review the new and changed features of the CMS audit protocol (CMS 10717) for CY 2022. Best practices for ODAG .

Overpayments 52

Overpayments Overpayment Compliance Medicare 52

Medisys Compliance

MAY 5, 2022

On 22 nd April 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare enrollment and eligibility rules that would expand coverage for people with Medicare and advance health equity. Sections 120 and 402 of the CAA made two key changes to Medicare enrollment rules.

Medicare 52

Medicare Medicare Medical Billing Outsourcing Medical Billing 52

Innovaare Compliance

JANUARY 3, 2022

January and February are usually busy months for Medicare Advantage Organizations (MAO). The Centers for Medicare & Medicaid Services (CMS) began call-center monitoring for timeliness and accessibility in 2015 and has continued since. This is an increase from two for 2022. The average rating in 2022 is 4.37

Compliance 40

Compliance Medicare Medicare Medicaid 40

Hall Render

FEBRUARY 27, 2023

billion in False Claims Act (“FCA”) related settlements and judgments in the federal fiscal year 2022. Whistleblowers continue to be one of the federal government’s greatest assets in FCA cases, as whistleblowers filed 652 qui tam suits in 2022 with recovery totaling $1.9 Health Care Fraud Actions Medicaid.

Nursing Homes 40

Nursing Homes Fraud Medicaid Medicaid 40

Hall Render

OCTOBER 31, 2022

The Centers for Medicare & Medicaid Services (“CMS”) has retooled guidance it armed surveyors with regarding how to survey skilled nursing facilities for compliance with the CMS staff vaccine requirements. CMS is replacing QSO memoranda 22-07-ALL Revised , 22-09-ALL Revised and 22-11-ALL. Background. Enforcement.

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Nurses Compliance COVID-19 COVID-19 Vaccine 40

AIHC

JANUARY 5, 2022

Written by: Joanne Byron , BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS As a result of the 2021 Consolidated Appropriations Act, several No Surprises Billing Act regulations went into effect on January 1, 2022, for providers, facilities and air ambulance services.

Medical Billing 52

Medical Billing Health Insurance Hospitals Medicare 52

Innovaare Compliance

MAY 26, 2022

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. The most prominent suspect was misrepresentation of services/products (48.87%).

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Fraud Medicare Medicare Medicaid 52

Healthcare Law Blog

NOVEMBER 2, 2023

According to the Congressional Research Service, which analyzed data from the Centers for Medicare & Medicaid Services (“CMS”) National Health Expenditure Accounts (“NHEA”) on the personal health expenditures for LTSS by payer, in 2021, an estimated $467.4 billion was spent on LTSS. This represents 13.2% of LTSS spending. [5]

Nursing Homes 52

Nursing Homes Medicaid Medicaid Medicare 52

Compliance Now

MAY 5, 2022

The Centers for Medicare and Medicaid Services recently opened the much-anticipated federal Independent Dispute Resolution (IDR) Portal , a component of the No Surprises Act section of the Consolidated Appropriations Act of 2021 (the Act). By: Jessica Waltman, Principal, Forward Health Consulting.

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Medicaid Medicaid Medicare Medicare 189

American Medical Compliance

AUGUST 1, 2022

In Spring 2022’s Semiannual Report to Congress (SAR), the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) reported that nearly $3 billion had been misspent on Medicare and Medicaid services. This includes recommending compliance programs or trainings for staff. Get Certified.

US Department of Health and Human Services 52

US Department of Health and Human Services COVID-19 Nursing Homes Medicare 52

Healthcare Law Blog

MAY 5, 2022

Department of Health and Human Services Office of Inspector (“OIG”) released a report that studied prior authorization denials and payment denials by Medicare Advantage Organizations (“MAOs”) (the “Report”). Thirteen percent of denied prior authorization requests met Medicare coverage rules. The OIG Report. additional test results).

Medicare 52

Medicare Medicare Licensing Health Insurance 52

Innovaare Compliance

MARCH 1, 2022

The monthly premium for Medicare Part B rose 14.5%, from $148.50 in 2022, which is partly offset by a cost-of-living increase of 5.9% By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1] in 2021 to $170.00 in Social Security benefits.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Health Law Advisor

FEBRUARY 10, 2023

Department of Justice (DOJ) released its annual False Claims Act (FCA) enforcement statistics for fiscal year (FY) 2022, which ended on September 30, 2022. [1] 2] DOJ’s press release touts the FY 2022 as having the second highest number of settlements in history. 1] While total recoveries exceeded $2.2 1] [link]. [2]

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Fraud COVID-19 Governance Medicaid 52

Healthcare Law Blog

MAY 16, 2022

On April 29, 2022 , the Centers for Medicare and Medicaid Services (“CMS”), issued the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (the “Final Rule”).

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Medicare Medicare Medicaid Medicaid 52

Innovaare Compliance

JANUARY 19, 2024

1] Focused audits will be limited in scope and duration and will only test the Compliance Program Effectiveness (CPE) and Organization Determinations, Appeals, and Grievances (ODAG) program areas during focused audits. An overview of the routine program audits was updated in December 2023 and is available on the CMS website. [1]

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Medicare Medicare Compliance Medicaid 52