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. To get paid, people would provide a severed rat tail and get a little cash.

Compliance 52

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

Provider Trust

MAY 18, 2022

Collectively referred to as vendors, these business relationships for healthcare organizations often include key suppliers such as durable medical equipment, contract employees, software and technology, janitorial services, and a plethora of other service providers. What the HHS-OIG says about vendor compliance.

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 meet MIPS requirements may receive more favorable Medicare reimbursement rates. The PI category comprises 25% of the total score.

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

Verisys

OCTOBER 11, 2023

It provides a 360-degree view of providers, employees, and entities, making it the most trusted and reliable dataset for provider sanctions, exclusions, and debarments. rely on FACIS ® to monitor their employee population in real time to ensure patient safety and compliance with regulatory requirements.

Compliance 52

Compliance Medicaid Medicaid 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

As of 2023, the penalty amount is up to $27,018 for each service provided in violation of the law, along with an assessment of up to three times the amount claimed for the services. Individuals or entities found in violation of Stark Law may face exclusion from participation in federal healthcare programs such as Medicare and Medicaid.

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. What is HIPAA and Who Does It Apply To?

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. One of these incentives is the Merit-Based Incentive Payment System, or MIPS. Find Out More!

Medicare 52

Medicare Medicare HIPAA Medicaid 52

MedTrainer

APRIL 18, 2024

Behavioral health credentialing exploded in 2023 and 2024 as providers could enroll in Medicare for the first time. With a whole new group of provider enrollments starting from scratch, credentialers will likely be juggling towers of documents and data for the foreseeable future.

Medicare 52

Medicare Medicare Licensing Compliance 52

Healthcare Law Blog

JANUARY 26, 2023

In this article we provide a brief summary of the Proposed Rule, while also examining the statutory amendments and previous rulemakings that create its foundation. BACKGROUND The Proposed Rule is the latest in a long line of federal legislation and rulemakings governing the conscience rights of healthcare providers and entities.

ACA 105

ACA Medicaid Medicaid Compliance 105

Hall Render

MARCH 20, 2024

CMS recently issued a final rule to require health care payers to improve communications between the payers, providers and patients and to improve the prior authorization processes (“Final Rule”). This process can lead to delays in necessary care, as well as immense frustration among providers and patients.

Medicare 40

Medicare Medicare Health Insurance Medicaid 40

AIHC

MAY 31, 2022

If you are a health care provider, remember that payers trust you to provide medically necessary, cost-effective, quality care. When the federal government covers items or services rendered to Medicare and Medicaid beneficiaries, the federal fraud and abuse laws apply.

Fraud 52

Fraud Compliance Officers Compliance Medicare 52

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. PDE provide the foundation for revenue reconciliation with drug plan sponsors (Sponsors) at the end of a contract year [1].

Medicare 52

Medicare Medicare Medicaid Medicaid 52

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

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

AIHC

NOVEMBER 29, 2023

Over the past decades, the traditional method of reimbursing providers was in a fee-for-service (FFS) model. A provider would see a patient, document the visit, and select the procedure code(s) for the service(s). Therefore, the provider would be reimbursed a fee for each service (CPT code) provided.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

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

Med-Net Compliance

JUNE 15, 2022

They alleged that between November 2011 and April 2018, the doctor defrauded Medi-Cal by knowingly billing for medical services, tests, and procedures which were not provided to patients. 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

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. Strengthen the limitations on uses and disclosures of Protected Health Information. Expand individuals’ rights to restrict disclosures of Protected Health Information.

HIPAA 78

HIPAA Compliance Health Insurance Medicaid 78

AIHC

NOVEMBER 29, 2023

Over the past decades, the traditional method of reimbursing providers was in a fee-for-service (FFS) model. A provider would see a patient, document the visit, and select the procedure code(s) for the service(s). Therefore, the provider would be reimbursed a fee for each service (CPT code) provided.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Medisys Compliance

FEBRUARY 9, 2024

Introduction For healthcare providers and billing specialists involved in wound care, staying abreast of regulatory changes is crucial for accurate reimbursement and efficient practice management. Providers should consult the latest CPT manual and coding resources to ensure they are using the correct codes for their services.

Medical Billing Outsourcing 59

Medical Billing Outsourcing Payment Systems Medical Billing Medicare 59

C&M Health Law

DECEMBER 23, 2022

The regulations impact CMS-regulated payers and provide incentives for providers and hospitals that participate in the Medicare Promoting Interoperability Program and the Merit-based Incentive Payment System (MIPS). Most of the Proposed Rule’s provisions will be effective on January 1, 2026. Our initial takeaways are summarized below.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

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

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. Office-Based Surgery: 18 standards deleted and one revised.

Hospitals 52

Hospitals Licensing Health Outcomes 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

Medisys Compliance

APRIL 15, 2024

Additionally, new Category I codes (64596, 64597, and 64598) have been introduced for integrated peripheral nerve stimulation procedures. Partnering for Success By staying informed about new urology codes, you can ensure your practice receives accurate reimbursement for the valuable services you provide.

Medical Billing Outsourcing 64

Medical Billing Outsourcing Medical Billing Medical Billing Services Medicaid 64

Hall Render

MARCH 1, 2023

Following this reporting, impacted providers and teaching hospitals will have until May 15, 2023, to review reported payments and investments and to dispute any incorrect reports. The registration process can take weeks to complete, so it is important for providers and teaching hospitals to register as soon as possible.

Hospitals 40

Hospitals Payment Systems Nurses Medical Device Industry 40

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

HIPAA Journal

JANUARY 9, 2023

Such major HIPAA updates placed a significant burden on HIPAA-covered entities and considerable time and effort were required to introduce new policies and procedures to ensure continued HIPAA compliance. Changing the Privacy Rule to make sharing PHI with other providers mandatory rather than permissible.

HIPAA 108

HIPAA COVID-19 COVID-19 Vaccine Compliance 108

AIHC

APRIL 5, 2022

Written by: AIHC Blogger This article provides educational information related to mitigating the risk of an unwarranted payer investigation. 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.

Fraud 52

Fraud Compliance Medicare Medicare 52

Medisys Compliance

APRIL 18, 2022

An Alternative Payment Model (APM) is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. CMMI considers APMs to be any arrangements whereby providers are held accountable for the quality and costs of care, not just paid based on the volume of services they deliver. APMs Overview.

Medical Billing 52

Medical Billing Medical Billing Outsourcing Medicaid Medicaid 52

Healthcare Law Blog

JANUARY 26, 2024

On December 13, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule, titled Advancing Interoperability and Improving Prior Authorization Processes (“Proposed Rule”), to improve patient and provider access to health information and streamline processes related to prior authorizations for medical items and services.

US Department of Health and Human Services 52

US Department of Health and Human Services Medicare Medicare Medicaid 52

Medisys Compliance

DECEMBER 29, 2023

Understanding the specific CPT codes within the range of 92920-93793 is crucial for healthcare providers navigating this complex landscape. Introduction The realm of cardiology encompasses a vast array of specialized services and procedures, demanding precise documentation and accurate coding for proper reimbursement. All rights reserved.

Medical Billing Outsourcing 59

Medical Billing Outsourcing Medical Billing Medicaid Medicaid 59

HIPAA Journal

MAY 12, 2023

One of the permissible disclosures of PHI in this category is for “case management and care coordination”. The Privacy Rule ( HIPAA §164.502(b)(2) ) also states the minimum necessary standard does not apply to disclosures to or requests by a health care provider for treatment. 42 CFR Part 2).

HIPAA 62

HIPAA Compliance Health Services Administration Medicare 62