AIHC

FEBRUARY 16, 2024

Lessons Learned about Consequences & Incentives Submitted by the AIHC Education Department Introduction The Office of Inspector General has released the new General Compliance Program Guidance or “GCPG” in late 2023. One of the seven items, #5 is “Enforcing Standards: Consequences and Incentives.”

Compliance 52

Compliance US Department of Health and Human Services COVID-19 Hospitals 52

AIHC

AUGUST 30, 2023

What compliance issues need to be considered when drafting a marketing strategy? Let’s take a closer look at potential compliance risks. As with all marketing strategies, remember Compliance, Compliance, Compliance! So, what is telemarketing in healthcare ? Great idea, right? I can’t say it enough.

Compliance 52

Compliance Fraud Medicare Medicare 52

Medisys Compliance

APRIL 25, 2024

MIPS focuses on four key performance categories: Quality: This measures the quality of care you provide to your patients based on specific metrics established by the Centers for Medicare & Medicaid Services (CMS). Improvement Activities: This category focuses on ongoing practice improvement initiatives to enhance patient care.

Medical Billing Outsourcing 64

Medical Billing Outsourcing Medical Billing Medicare Medicare 64

Provider Trust

MAY 18, 2022

What the HHS-OIG says about vendor compliance. If the answer is yes, then the best mechanism for limiting CMP liability is to screen all persons that perform under that contract or that are in that job category. In addition, the suit involved alleged submission of false claims for reimbursement to the Massachusetts Medicaid Agency.

Compliance 52

Compliance Due Diligence Medicaid Medicaid 52

Compliancy Group

OCTOBER 5, 2023

Under MACRA, the Centers for Medicare and Medicaid Services (CMS) created regulations to encourage healthcare providers to use secure health information technology. Providers who earn a total score (based on their performance in all four categories) of 75.1% The PI category comprises 25% of the total score. Please Wait.

HIPAA 52

HIPAA Medicare Medicare Compliance 52

Med-Net Compliance

OCTOBER 21, 2022

The OIG applies published criteria to assess future risk and places each party to an FCA settlement into one of five categories on a risk spectrum. The OIG uses its exclusion authority differently for parties in each category and bases its assessment on the information it has reviewed in the context of the resolved FCA case.

Fraud 59

Fraud Compliance Medicare Medicare 59

C&M Health Law

JANUARY 18, 2023

On January 4, in its most recent effort to expand federal support for addressing health-related social needs (HRSNs), the Centers for Medicare & Medicaid Services (CMS) issued guidance to clarify an existing option for states to address HRSNs through the use of “in lieu of” services and settings policies in Medicaid managed care.

Medicaid 52

Medicaid Medicaid Health Outcomes Federal Policy 52

Innovaare Compliance

FEBRUARY 14, 2022

Healthcare organizations establish Compliance Departments with the primary purpose of providing compliance oversight for the organization. Operational teams—such as the Member Services Department and the Appeals & Grievances Department—have significant compliance regulations, so they must know to maintain compliance.

Compliance 52

Compliance Regulatory Compliance Medicaid Medicaid 52

Med-Net Compliance

JULY 20, 2022

A federal jury convicted a New York ENT doctor for defrauding Medicare and Medicaid by causing the submission of false and fraudulent claims for surgical procedures that were not performed. Specifically, between January 2014 and February 2018, the doctor billed Medicare and Medicaid approximately $585,000 and was paid approximately $191,000.

Fraud 59

Fraud Doctors Medicare Medicare 59

MedTrainer

JUNE 29, 2023

Individuals or entities found in violation of Stark Law may face exclusion from participation in federal healthcare programs such as Medicare and Medicaid. Organizations that violate Stark Law may also face the loss of Medicare and Medicaid reimbursements. Awareness of compliance risks. What are Designated Health Services?

Compliance 52

Compliance Compliance Officers Medicaid Medicaid 52

HIPAA Journal

DECEMBER 31, 2022

To best answer the question what is a HIPAA violation, it is necessary to explain what HIPAA is, who it applies to, and what constitutes a violation; for although most people believe they know what a HIPAA compliance violation is, evidence suggests otherwise. HIPAA Violation Categories. There are four HIPAA violation categories.

HIPAA 132

HIPAA Due Diligence Compliance Fraud 132

Compliancy Group

NOVEMBER 16, 2022

Under MACRA, the Centers for Medicare and Medicaid Services created regulations for healthcare providers’ use of health information technology. MIPS is composed of four performance categories, on which providers are graded. These categories include quality, cost, improvement activities, and promoting interoperability.

Medicare 52

Medicare Medicare HIPAA Medicaid 52

Hall Render

JANUARY 18, 2022

Amidst a nationwide nursing and skilled nursing facility staffing crisis, the Centers for Medicare & Medicaid Services (“CMS”) announced that additional information regarding nursing home staff numbers will be added to the January 2022 CMS Care Compare website.

Nurses 40

Nurses Nursing Homes Compliance Licensing 40

Hall Render

OCTOBER 10, 2023

As nursing homes look for funds to allow them to improve care and train nursing home staff, Centers for Medicare & Medicaid Services (“CMS”) released QSO-23-23-NH (“CMS Memo”), which reopens and recasts the Civil Money Penalty Reinvestment Program (“CMPRP”).

Nursing Homes 40

Nursing Homes Nurses Medicaid Medicaid 40

Innovaare Compliance

MARCH 11, 2024

The Centers for Medicare & Medicaid Services (CMS) has been processing Part D drug claim data via the Drug Data Processing System (DDPS) since inception of Part D in 2006. Effective January 1, 2024, category 4 beneficiaries will have the same Part D benefit parameters as beneficiaries in LIS category 1 [7].

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Med-Net Compliance

JUNE 15, 2022

During the course of the investigation, documentation from his office revealed five categories of medical services which were the focus of the fraudulent billing schemes. Issue: It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.

Fraud 59

Fraud Doctors Elder Abuse Medicare 59

AIHC

MAY 31, 2022

When the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply. Implementing a successful compliance program not only assists in protecting your organization but individuals within the organization. Now, let’s talk more about qui tam action.

Fraud 52

Fraud Compliance Officers Compliance Medicare 52

Hall Render

MARCH 20, 2024

The Final Rule also imposes additional reporting requirements under the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals and for eligible clinicians reporting under the Promoting Interoperability performance category of the Merit-Based Incentive Payment System.

Medicare 40

Medicare Medicare Health Insurance Medicaid 40

Healthcare Law Blog

JANUARY 26, 2023

Medicaid and Medicare The Balanced Budget Act of 1997, Public Law 105–33, 111 Stat. The Medicaid and Medicare statutes also contain conscience provisions related to the performance of advanced directives, religious nonmedical healthcare providers and their patients.

ACA 105

ACA Medicaid Medicaid Compliance 105

Healthcare Law Blog

NOVEMBER 13, 2023

On November 6, 2023, the Centers for Medicare and Medicaid Services (“CMS”) released the contract year 2025 proposed rule for Medicare Advantage (“MA”) organizations and Part D sponsors (the “Proposed Rule”). This proposal would shift the burden from CMS to the MA organization to demonstrate compliance with this standard.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

HIPAA Journal

JANUARY 12, 2024

The key provisions of the HIPAA Omnibus Rule were: Make business associates of covered entities directly liable for HIPAA compliance. One of the concerns with regards to the lack of HIPAA compliance is that large scale changes to HIPAA are forecast over the next few years.

HIPAA 78

HIPAA Compliance Health Insurance Medicaid 78

MedTrainer

APRIL 18, 2024

Here are some of the most common challenges for behavioral health credentialing and Medicare enrollment: Understanding Medicare Requirements: The Center for Medicare and Medicaid (CMS) divides counselors into two main categories: marriage and family therapist (MFT) and mental health counselor (MHC).

Medicare 52

Medicare Medicare Licensing Compliance 52

Compliance Now

JANUARY 13, 2022

The limits for 2023, as announced by the Centers for Medicare and Medicaid Services, are listed below in comparison to the 2022 limits: Out-of-Pocket Limits Coverage Type 2022 2023 Self-Only Coverage $8,700 $9,100 Family Coverage $17,400 $18,200. Premiums and spending for non-covered services do not count towards the out-of-pocket limits.

ACA 113

ACA Health Insurance Medicaid Medicaid 113

AIHC

NOVEMBER 29, 2023

The Centers for Medicare & Medicaid Services (CMS) HCC model was initiated in 2004 and is becoming increasingly prevalent as the environment shifts to value-based payment models. It’s important for compliance and historical trend analysis. The poor quality of care, inefficiencies, and total cost to the U.S.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

Hall Render

FEBRUARY 14, 2023

Targeted Audits In the rule and accompanying release, CMS provided that it will conduct RADV audits targeted at diagnosis categories that it deems more likely to be reported in error (referred to as high-risk Hierarchical Condition Categories, rather than its previous method of an untargeted random sample methodology.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

AIHC

NOVEMBER 29, 2023

The Centers for Medicare & Medicaid Services (CMS) HCC model was initiated in 2004 and is becoming increasingly prevalent as the environment shifts to value-based payment models. It's important for compliance and historical trend analysis. The poor quality of care, inefficiencies, and total cost to the U.S.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Innovaare Compliance

FEBRUARY 7, 2022

Health plans (collectively, “plan sponsors”) that contract with the Centers for Medicare & Medicaid Services (CMS) to provide health services to eligible Medicare beneficiaries are responsible for legal, contractual, and fiduciary obligations whether performed by the plan or those to whom the company delegates those obligations.

Compliance 52

Compliance Medicare Medicare Medicaid 52

Provider Trust

JANUARY 26, 2022

Let’s start with the role of the OIG, which is tasked with ensuring that dollars for federal healthcare programs such as Medicare, Medicaid, CHIPS, and TriCare, as well as other healthcare federal grant monies, are judiciously spent and awarded as reimbursements for quality care that is not fraudulent. So what are the risk categories?

Fraud 52

Fraud US Department of Health and Human Services Medicaid Medicaid 52

Health Law Advisor

APRIL 10, 2023

This interpretation provided to be difficult to apply in real world situations because while we all might think of Amazon and WalMart as big-box stores, it was not clear what other stores might also fall into this category and present a compliance risk.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Hall Render

MARCH 1, 2023

Reminder: Reporting on Additional Covered Recipients and Nature of Payment Categories Began in 2022 Covered Recipients Prior to 2021, only physicians (excluding medical residents) and teaching hospitals were included in the definition of Covered Recipients.

Hospitals 40

Hospitals Payment Systems Nurses Medical Device Industry 40

AIHC

APRIL 5, 2022

Prior to appealing a Medicare, Medicaid, TriCare or other Federal Program claim, you should verify that your organization is compliant in this area ( click here ). Diagnosis codes are an important compliance aspect of reporting medical necessity on the claim. If in doubt, check it out.

Fraud 52

Fraud Compliance Medicare Medicare 52

C&M Health Law

DECEMBER 23, 2022

The below summary does not focus on the Medicaid and Children’s Health Insurance Program (CHIP) Fee for Service (FFS) proposals. This proposed reporting would be at the organizational level for MA, the state level for Medicaid and CHIP FFS, the plan level for Medicaid and CHIP managed care, and the issuer level for QHP issuers on the FFEs. (iv)

Medicare 59

Medicare Medicare Medicaid Medicaid 59

Medisys Compliance

DECEMBER 29, 2023

Other Therapeutic Cardiovascular Procedures Beyond the categories mentioned above, this range also encompasses various additional therapeutic procedures, including: Pericardiocentesis (93505): Removal of fluid from the pericardial sac surrounding the heart. All rights reserved.

Medical Billing Outsourcing 59

Medical Billing Outsourcing Medical Billing Medicaid Medicaid 59

Healthcare Law Today

JANUARY 2, 2023

The Joint Commission accredits many different categories of health care providers, including hospitals, critical access hospitals, assisted living communities, ambulatory care organizations, home care entities, and laboratories. The review also took into account the opinions of experts within the field.

Hospitals 52

Hospitals Licensing Health Outcomes Medicaid 52

Medisys Compliance

APRIL 18, 2022

In October 2021, the Center for Medicare and Medicaid Innovation (CMMI) announced a goal of having every Medicare beneficiary and the majority of Medicaid beneficiaries covered by some type of alternative payment model (APM) by 2030. Incentives for Medicaid clinicians who also treat Medicare patients. Advanced & MIPS APMs.

Medical Billing 52

Medical Billing Medical Billing Outsourcing Medicaid Medicaid 52

Hall Render

DECEMBER 4, 2023

The Centers for Medicare & Medicaid Services (“CMS”) finalized significant updates to the Hospital Price Transparency regulation for the first time since the rule took effect on January 1, 2021. Hospitals must continue to include the payer-specific negotiated rates, along with the other standard charges.

Hospitals 52

Hospitals Compliance Patient Advocacy Medicare 52

Healthcare Compliance Blog

MARCH 15, 2022

This allegation includes over reporting the number of hours that nurses provided care to residents to the Centers for Medicare & Medicaid Services (CMS). Allegedly, this over reporting to CMS resulted in fraudulently increasing the facilities’ star ratings in some categories.

Nurses 59

Nurses Fraud Medicaid Medicaid 59