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.

Compliance 52

Compliance Compliance Officers Governance Overpayments 52

YouCompli

FEBRUARY 1, 2023

Using the OIG’s seven elements as a guide to delivering better patient care Healthcare Compliance professionals tend to focus, rightfully so, on the regulations and organization requirements around providing quality patient care and keeping patients safe. Compliance officers have three main roles in this.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

YouCompli

OCTOBER 26, 2022

Helping our clinical colleagues feel the urgency of compliance monitoring can be a huge challenge. And the Compliance team simply doesn’t have the clinical expertise to own the monitoring of these requirements. That’s a 41% error rate with an extrapolated overpayment of?$269 Don’t let processes overwhelm clinical colleagues.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

Health Law RX

JANUARY 30, 2024

By maintaining a robust compliance program, healthcare companies are better able to identify potential red flags early and to prevent violations of fraud and abuse laws. The DOJ Announcement stresses the importance of investing in strong compliance programs for both the buyers and sellers in business transactions.

Compliance 52

Compliance Due Diligence Fraud Governance 52

YouCompli

DECEMBER 14, 2022

Sharon Parsley, JD, MBA, CHC, CHRC contributes a monthly post on compliance officer effectiveness for the YouCompli blog. Many people in our discipline love the slogan “compliance is everybody’s business.” In the process, they became compliance champions. Seize every opportunity to demonstrate that compliance is not the police.

Compliance 52

Compliance Compliance Officers Nurses Overpayments 52

Healthcare IT Today

JANUARY 17, 2024

External Audits Surge Among the report’s standout findings is the significant uptick in external payor audits in 2023, a result of escalating federal government efforts to address the overpayments made in the past two to three years. These challenges account for 16% of overall denials, amounting to $17 billion from the sampled data.

Compliance 109

Compliance Overpayments Overpayment Medicare 109

Compliancy Group

FEBRUARY 7, 2024

You may have been hearing about UPIC (Unified Program Integrity Contractor) audits more often lately. For healthcare organizations, understanding UPIC audits and preparing for them is essential to compliance. The outcome of these audits can range from repayment of overpayments to criminal prosecution in cases of fraud.

Fraud 52

Fraud Compliance Medicare Medicare 52

Health Care Law Brief

APRIL 12, 2023

MA plans will be required to have a Utilization Management Committee that conducts annual reviews of policies to ensure compliance with the foregoing. Notable Omissions from Proposed Rule CMS declined to adopt previously proposed amendments to the standard for “identified overpayments” under Medicare Parts A, B, C, and D. See 42 U.S.C.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

YouCompli

SEPTEMBER 13, 2023

Mitigating fraud, waste, and abuse (FWA) is taking on a new urgency for healthcare compliance professionals. This three-pronged strategy focuses on educating patients and staff about how to avoid misconduct. It also emphasizes training individuals on how to recognize and report FWA violations when they see them.

US Department of Health and Human Services 52

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

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.

Hospitals 52

Hospitals Compliance Officers Compliance Overpayments 52

Healthcare IT Today

NOVEMBER 22, 2022

Auditors may also perform technical audit reviews, medical necessity compliance reviews, and medical policy reviews. The payer could also recoup the overpayments from future visits. . About John Wallace. Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. What Triggers Audits? .

Medicare 96

Medicare Medicare Overpayments Overpayment 96

Med-Net Compliance

OCTOBER 21, 2022

Because the OIG’s assessment of the risk posed by a FCA defendant may be relevant to various stakeholders, including patients, family members, and healthcare sector professionals, the information about where a FCA defendant falls on the risk spectrum is made public.

Fraud 59

Fraud Compliance Medicare Medicare 59

Innovaare Compliance

MARCH 24, 2024

They also raised concerns about the fairness and accuracy of the AI algorithms, suggesting that the system might be biased against certain types of providers or services. Poor dispute resolution could lead to compliance risks, reputational damage, and even loss of key providers.

Fraud 52

Fraud Health Insurance Compliance Medicaid 52

Healthcare IT Today

FEBRUARY 2, 2024

Payment integrity is essential for ensuring financial accuracy, maintaining compliance with regulations, optimizing the healthcare delivery system, and removing administrative waste, which impacts the focus on patient care and quality outcomes. This reactive model leads to only ~70% of identified overpayments being recovered and/or corrected.

Payment Systems 68

Payment Systems Overpayments Overpayment Medical Billing 68

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. Telemedicine is considered to be under the umbrella of telehealth and refers specifically to clinical services.

COVID-19 59

COVID-19 Telemedicine Compliance Informed Consent 59

Healthcare IT Today

FEBRUARY 2, 2023

One last note about conducting quality assurance audits: Remember to close the loop. Episource works with a regional healthcare organization that has added an annual compliance retrospective in the months leading up to the final submission deadline. did the provider education improve documentation?).

Medicare 61

Medicare Medicare Medicaid Medicaid 61

AIHC

APRIL 5, 2022

If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back. Diagnosis codes are an important compliance aspect of reporting medical necessity on the claim. Never file an appeal when you believe documentation may be evidence of fraud or abuse.

Fraud 52

Fraud Compliance Medicare Medicare 52

Healthcare IT Today

MAY 5, 2023

By taking a proactive, data-driven approach to genetic testing fraud, waste and abuse, health plans can protect members from unnecessary testing, prevent inappropriate claims from being paid, and improve their chances of recovery when an overpayment occurs.

Fraud 63

Fraud Medicare Medicare Overpayments 63

CMS.gov

NOVEMBER 16, 2018

These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred. This is the second consecutive year the rate has been below the 10 percent threshold for compliance established in the Improper Payments Elimination and Recovery Act of 2010. . percent in 2017 to 8.12

Medicare 20

Medicare Medicare Overpayments Overpayment 20

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

US Department of Health and Human Services 40

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

AIHC

MARCH 28, 2022

But first, learn more about how a complex payer audit system works. For example, the GAO states that they identified about $77.6 billion in financial benefits in fiscal year 2020— a return of about $114 for every $1 invested. Make sure to read Part 1: Managing Denials is Important to Good A/R Hygiene. Audited by a payer?

Medicare 52

Medicare Medicare Compliance Governance 52

Healthcare Law Blog

MARCH 2, 2023

Once CMS acknowledges receipt of a provider’s SRDP submission, the provider’s obligation to report and return overpayments within 60 days is suspended. If you have any questions about the SRDP process or recent changes to the SRDP’s required forms, please contact any member of our Health Care Team for assistance. See 42 C.F.R.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

Medisys Compliance

MARCH 7, 2022

An EHR system provides accurate, up-to-date information about the patient. This is the history of the problem, but there is usually something unique to say about the patient’s status spanning the period between the last appointment and the current one. Accurate Information in EHR. Interval HPI.

Medical Billing 52

Medical Billing Medical Billing Outsourcing Overpayments Overpayment 52

AIHC

MARCH 22, 2022

Monitor Reports for Inappropriate Write-Offs Are accounts reconciled and overpayments identified and handled properly? Revenue Cycle Managers are encouraged to obtain some training in compliance auditing. The post Part 1: Managing Denials Is Important to Good A/R Hygiene appeared first on American Institute of Healthcare Compliance.

Overpayments 52

Overpayments Overpayment Compliance Medicare 52

Hall Render

AUGUST 26, 2022

Compliance with Oct. Oklahoma doctor raises concerns about life-threatening virus, polio. Charles workers launch petition, refuse to repay overpayments without outside audit; union files BOLI complaint. Project to bring about 216 senior housing units to McKinney. CMS proposes mandatory Medicaid, CHIP quality reporting.

Nursing Homes 40

Nursing Homes COVID-19 Nurses Hospitals 40

Healthcare Law Blog

JANUARY 5, 2023

The Proposed Rule includes changes on an array of topics including: Star Ratings, medication therapy management, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, behavioral health services, identification of overpayments , requirements for valid contract applications, and formulary changes.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Hall Render

MARCH 22, 2024

NATIONAL 79 percent have positive outlook for senior living and care: NIC 12 key legal issues impacting health systems AHA: 94% of hospitals financially impacted by Change Healthcare’s cyberattack A conversation about the HHS plan on AI in health care A new kind of hospital is coming to rural America.

Nursing Homes 40

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