Healthcare IT Today

MAY 5, 2023

The following is a guest article by Erin Rutzler, Vice President of Fraud, Waste, and Abuse at Cotiviti In Delaware, more than 250 Medicare patients underwent unnecessary genetic testing based on telehealth consultations that often lasted less than two minutes— costing Medicare thousands of dollars per patient. In 2021, a U.S.

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Fraud Medicare Medicare Overpayments 62

Provider Trust

JUNE 30, 2023

Maintaining the highest payment integrity standards helps payers avoid unnecessary payments, recover overpayments, and prevent fraud, waste, and abuse (FWA) in healthcare billing. This means payers must rely on post-payment reviews and audits to identify those errors, overpayments, and fraudulent claims.

Overpayments 52

Overpayments Overpayment Fraud Compliance 52

Health Care Law Brief

APRIL 12, 2023

405.986) or “reliable evidence” of fraud or “similar fault” (as defined in 42 C.F.R. MA plans will be required to have a Utilization Management Committee that conducts annual reviews of policies to ensure compliance with the foregoing. Final Rule at p. 3729(b)(1)(A) of the False Claims Act (“FCA”). See Proposed Rule at 79559.

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Medicare Medicare Overpayments Overpayment 52

Compliancy Group

FEBRUARY 7, 2024

CMS UPIC audits are designed to identify and prevent fraud, waste, and abuse within Medicare and Medicaid, ensuring that federal funds are used appropriately and that the services billed for are actually provided and are medically necessary. Given their significant impact, healthcare organizations must take UPIC audits seriously.

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Fraud Compliance Medicare Medicare 52

C&M Health Law

DECEMBER 18, 2023

Department of Health and Human Services (HHS) published the General Compliance Program Guidance (GCPG) on November 6, 2023. The GCPG provides updated descriptions of the seven elements of an effective compliance program that health care entities have long relied upon. The Office of the Inspector General (OIG) of the U.S.

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Compliance Compliance Officers Governance Overpayments 52

Innovaare Compliance

MARCH 24, 2024

The Importance of Payment Integrity Payment integrity is crucial for health plans to control costs, reduce fraud, waste, and abuse (FWA), and ensure the accuracy of healthcare payments. billion in healthcare fraud judgments and settlements. billion in healthcare fraud judgments and settlements.

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Fraud Health Insurance Compliance Medicaid 52

Compliancy Group

FEBRUARY 29, 2024

By examining the purpose and regulatory mechanisms of these agreements, we can understand their role in ensuring compliance, promoting ethical conduct, and ensuring patient and employee safety. When a hospital, doctor’s office, or other healthcare organization is guilty of a regulatory or compliance violation , the U.S.

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Compliance Compliance Officers Overpayments Overpayment 52

YouCompli

SEPTEMBER 13, 2023

Mitigating fraud, waste, and abuse (FWA) is taking on a new urgency for healthcare compliance professionals. Integrating this strategy into your compliance culture can help your organization avoid penalties and deliver compliant patient care. For staff, compliance officers should support annual online FWA compliance training.

US Department of Health and Human Services 52

US Department of Health and Human Services Compliance Officers Compliance Fraud 52

Med-Net Compliance

OCTOBER 21, 2022

The government’s primary civil tool for addressing healthcare fraud is the FCA. The risk categories are described as follows: Highest Risk—Exclusion: Parties that the OIG determines present the highest risk of fraud will be excluded from Federal healthcare programs to protect those programs and their beneficiaries.

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Fraud Compliance Medicare Medicare 59

Healthcare Law Blog

FEBRUARY 9, 2024

million to resolve a lawsuit filed by the system’s former Chief Compliance Officer, Ronald Sherman. Global billing or collaborative care arrangements are not per se violations of the Anti-Kickback Statute, however, there is greater fraud and abuse risk in these types of arrangements unless there is active, ongoing monitoring for compliance.

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Hospitals Compliance Officers Compliance Overpayments 52

Health Law Blog

MAY 22, 2018

Substance Abuse Treatment Center Fraud Scheme Results in Guilty Plea. The Department of Justice recently announced the guilty plea of two individual alcohol and substance abuse treatment center owners for their participation in what DOJ labeled a “multi-million dollar health care fraud and money laundering scheme.”

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Fraud Overpayments Overpayment Licensing 52

AIHC

APRIL 5, 2022

Due to the huge volume of claims payers receive to process, deny and pay, they have implemented various methods to track providers to detect potential waste, fraud and/or abuse. If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back.

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Fraud Compliance Medicare Medicare 52

Healthcare Compliance Blog

JUNE 9, 2022

In March of 2022, in a related matter, the man pleaded guilty to Healthcare Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the US Department of Health and Human Services between 2016 and 2020. He is awaiting sentencing on those charges.

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US Department of Health and Human Services Medicare Medicare Overpayments 59

Healthcare IT Today

FEBRUARY 2, 2023

It has given every indication that it intends to investigate fraud, waste, and abuse more robustly in the foreseeable future. The Justice Department has joined the fraud case against one large national insurer. At $1,000 per code, these errors pointed to a possible overpayment of $64,000 for the identified members.

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Medicare Medicare Medicaid Medicaid 59

AIHC

SEPTEMBER 5, 2023

Compliance Considerations for Best Outcomes Written in collaboration with the AIHC Volunteer Education Committee Delivering mental health services via telehealth has increased since the COVID-19 pandemic. This includes understanding various fraud and abuse laws. Telehealth rules and regulations vary greatly by state.

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Telemedicine COVID-19 Compliance Informed Consent 59

CMS.gov

NOVEMBER 16, 2018

Fraud, waste, & abuse. Improper payments are not necessarily measures of fraud, but instead are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements. These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred.

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Medicare Medicare Overpayments Overpayment 20

Florida Health Care Law Firm

DECEMBER 2, 2021

On November 8, 2021, The Department of Health & Human Services (HHS), Office of Inspector General (OIG) released a revised and renamed Provider Self-Disclosure Protocol (SDP), now known as the “Health Care Fraud Self Disclosure “protocol. The OIG recognized that there are benefits to disclose potential fraud.

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Overpayments Overpayment Fraud Medicare 40

Medisys Compliance

MARCH 7, 2022

These are usually just innocuous mistakes that do not represent any intent to commit billing fraud. In the unfortunate event when you receive such overpayment demand letters, don’t acquiesce without conducting an analysis first. One error of this nature can lead to a reviewer casting aspersions on the integrity of your note.

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Medical Billing Medical Billing Outsourcing Overpayments Overpayment 52

Hall Render

JUNE 30, 2023

for physician referral scheme In Los Angeles, hospital CEO pay could be capped Kaiser Permanente ratings affirmed amid healthy financial profile Nurses vote ‘no confidence’ in California hospital administration, board Nursing facility, management company settle physician kickback allegations for $3.8M

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US Department of Health and Human Services Nursing Homes Nurses Hospitals 40

AIHC

MARCH 28, 2022

The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. G is the field on the 1500 claim being audited for MUE compliance: These edits are updated at least quarterly and revised in your practice management system through updates to the software.

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Medicare Medicare Compliance Governance 52

Hall Render

AUGUST 26, 2022

Compliance with Oct. Charles workers launch petition, refuse to repay overpayments without outside audit; union files BOLI complaint. CHS faces class-action fraud suit. Health care giant to pay Washington $19M to resolve allegations of Medicaid fraud. CMS bulletin presses states on Medicaid nursing home spending.

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Nursing Homes COVID-19 Nurses Hospitals 40

Hall Render

MARCH 22, 2024

Banner Health to expand clinical AI to 33 hospitals, 6 states Banner reports $282.8M family sues hospital over life-altering injuries Calif. Nevada Medicaid must cover abortion services, judge rules Clark County health rankings improve, but physicians per capita still well below U.S.

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Nursing Homes US Department of Health and Human Services Nurses Hospitals 40