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Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program

Healthcare Law Blog

New Subpart 521-1: Compliance Programs The adopted regulations represent substantial changes to 18 N.Y.C.R.R. Part 521 governing the implementation and operation of effective compliance programs for certain “required providers,” including, now for the first time, Medicaid managed care organizations (MMCOs). [1]

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New York State OMIG Makes Regulatory Modifications to Compliance Program Requirements

Health Law Advisor

It is axiomatic that New York State requires every Medicaid provider to have an “effective” compliance program. These regulations were proposed to implement portions of the New York State 2020-2021 Budget Bill amending the mandatory compliance program requirements. New York Social Services Law § 363-d.


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Compliance Risks Associated with Outlier Payments 


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 government alleged these increased charges resulted in the greater number of outlier payments.

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OIG Issues Updated General Compliance Program Guidance: Overview of Key Elements & Changes

C&M Health Law

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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The Trebling Effect of (Some) False Claims Act Trials

Health Law RX

Setting aside the incalculable impact that litigation can have on business operations, the statute itself anticipates repayment of the proven overpayment, treble damages, and exposure to a civil statutory penalty equal to a range between $13,508 and $27,018 per false claim. This is the reality for a medical company in Minnesota.

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Increasing Enforcement of Modifier Codes 


Two of the most significant healthcare compliance risks are medical coding and billing. Enforcement agencies like to “follow the money,” so to speak, and they often find it in medical claims submitted to government payors such as Medicare and Medicaid. The hospital ultimately settled and agreed to pay $3.3 CJ Wolf, MD, M.Ed.

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Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare

Innovaare Compliance

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 Poor dispute resolution could lead to compliance risks, reputational damage, and even loss of key providers. billion in healthcare fraud judgments and settlements.

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