Healthcare Law Blog

FEBRUARY 3, 2023

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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Medicaid Medicaid Compliance Overpayments 52

YouCompli

NOVEMBER 1, 2023

As compliance officers, we are continually placed in a position to influence the actions of others and help shape our organization’s compliance culture. One way to change that perception is to avoid creating “gotcha” moments when you’re working on a compliance-related matter. Here are four tips that will help.

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

YouCompli

FEBRUARY 22, 2023

Raising prices on your hospital’s chargemaster can also raise your level of compliance grief. Compliance officers can help protect revenue and reduce the risk of penalties by collaborating with the Finance and Reimbursement departments to navigate the dynamics of outlier payments and prospective repayment.

Compliance 52

Compliance US Department of Health and Human Services Overpayments Overpayment 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

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.

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Compliance Compliance Officers Overpayments Overpayment 52

Healthicity

NOVEMBER 29, 2022

Health and Human Services Office of Inspector General (OIG) recently issued a report concluding that Medicare and patients combined overpaid more than a million dollars for the same professional services provided at critical access hospitals (CAH). Who Bills for Professional Services?

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Overpayments Overpayment Hospitals Medicare 52

Healthcare Law Blog

FEBRUARY 9, 2024

million to resolve a lawsuit filed by the system’s former Chief Compliance Officer, Ronald Sherman. Sherman alleged that these “in-kind” services constituted improper remuneration that was intended to induce the physicians to make referrals to ChristianaCare. ChristianaCare did not admit liability as part of the settlement.

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Hospitals Compliance Officers Compliance Overpayments 52

YouCompli

MAY 17, 2023

Sharon Parsley, JD, MBA, CHC, CHRC contributes a regular post on compliance officer effectiveness for the YouCompli blog. What does it really take to ensure that an organization has a mature, well-integrated, and high-performing Compliance function? Hopefully, both Compliance and Legal are involved in your contract approval processes.

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Compliance Compliance Officers Overpayments Overpayment 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.

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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.

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Compliance Due Diligence Fraud Governance 52

McBrayer Law Blog

NOVEMBER 18, 2020

The estimated overpayment as a result of these coding errors is a reported $1 billion. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims.

Compliance 52

Compliance Overpayments Overpayment Medicare 52

Healthcare Compliance Blog

MARCH 16, 2022

In a March 11, 2022, release by the Northern District of Georgia’s Office of the Department of Justice, it was reported that an investigation determined a Georgia nursing home knowingly submitted claims for unreasonable, unnecessary, and unskilled services for Medicare patients. This amount was based on the nursing home’s ability to pay.

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Nursing Homes Nurses Overpayments Overpayment 59

Provider Trust

JUNE 30, 2023

Payers within the healthcare ecosystem understand the complexities and importance of maintaining integrity when submitting or evaluating payments for medical services rendered by providers. This means payers must rely on post-payment reviews and audits to identify those errors, overpayments, and fraudulent claims.

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Overpayments Overpayment Fraud Compliance 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

Compliancy Group

FEBRUARY 7, 2024

This is because the Centers for Medicare & Medicaid Services (CMS) have ramped up their efforts to identify organizations that have improperly billed for medical services. For healthcare organizations, understanding UPIC audits and preparing for them is essential to compliance. What is the Purpose of UPIC Audits?

Fraud 52

Fraud Compliance Medicare Medicare 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.

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Compliance Overpayments Overpayment Medicare 106

Health Care Law Brief

APRIL 12, 2023

On April 5, the Centers for Medicare & Medicaid Services (“CMS”) released the 2024 Medicare Advantage and Prescription Drug Benefit Programs Final Rule (“Final Rule”), which will be codified at 42 C.F.R. Any overpayment retained by a person after the deadline for reporting and returning an overpayment is an obligation under the FCA.

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. Enforcement agencies are prioritizing efforts to deter FWA as more individuals enroll in government healthcare programs like Medicare and Medicaid, and telehealth services continue to evolve post-pandemic.

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

Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 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.

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Fraud Health Insurance Compliance Medicaid 52

Healthcare IT Today

NOVEMBER 22, 2022

After all, more patients should generate more billable services—and thus, more payments. They also look to flag “items and services that have high national error rates and are a financial risk to Medicare.” Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. What Triggers Audits? .

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Medicare Medicare Overpayments Overpayment 94

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.

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COVID-19 Telemedicine Compliance Informed Consent 59

Healthcare Compliance Blog

APRIL 14, 2022

Research by the Centers for Medicare & Medicaid Services (CMS) has found that many hospital admissions of dually eligible nursing home residents could have been avoided because the condition could have been prevented or treated outside of an inpatient hospital setting. Update as needed.

Medicare 59

Medicare Medicare Overpayments Overpayment 59

Innovaare Compliance

MARCH 1, 2022

1] The Centers for Medicare & Medicaid Services (CMS) has to establish an annual Part B premium that will adequately fund projected Medicare spending and maintain an adequate reserve in case actual costs are higher than estimated. Making proper payments for Part C and D services is also a statutory requirement. [6]

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Innovaare Compliance

JUNE 28, 2022

The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of CMS program audits in February 2022. Part B drug is a new data field in Table 1 Standard and Expedited Pre-Service Requests for Organization Determinations (OD). . Compliance Standard and Method of Evaluation are outlined in the protocol. .

Overpayments 52

Overpayments Overpayment Compliance Medicare 52

Healthcare IT Today

MAY 5, 2023

Department of Health and Human Services (HHS) analysis showed Medicare payments for genetic testing quadrupled from 2016 to 2019. This modifier should only be used when any other modifier is not specific or appropriate enough to depict the reason for the service or procedure. In 2021, a U.S.

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Fraud Medicare Medicare Overpayments 62

Healthcare Compliance Blog

JUNE 9, 2022

His exclusion means that no federal healthcare program payment may be made, either directly or indirectly, for any items or services furnished by him or at his direction or prescription. Additionally, the Pennsylvania man agreed to be excluded from all federal healthcare programs for 22 years. 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

These programs stress the importance of arriving at supportable diagnoses and charting the diagnoses effectively, which leads to more accurate submissions to the Centers for Medicare & Medicaid Services (or CMS). At $1,000 per code, these errors pointed to a possible overpayment of $64,000 for the identified members.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

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. Place of Service (POS) can be a “trigger” for an investigation. at: [link] Is the date of service (DOS) correct? Audit the POS to ensure this was coded correctly on the claim.

Fraud 52

Fraud Compliance Medicare Medicare 52

Health Law Blog

MAY 22, 2018

The two individuals owned a licensed substance abuse service provider (or treatment center) offering clinical treatment services for persons suffering from alcohol and drug addiction. A great deal of expense goes into assuring that these providers are in complete compliance.

Fraud 52

Fraud Overpayments Overpayment Licensing 52

CMS.gov

NOVEMBER 16, 2018

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Administrator, Centers for Medicare & Medicaid Services. 2018 Medicare Fee-For-Service improper payment rate is lowest since 2010 Significant progress in saving $4.59B in estimated improper payments for the Medicare Fee-For-Service program.

Medicare 20

Medicare Medicare Overpayments Overpayment 20

YouCompli

SEPTEMBER 27, 2023

Two of the most significant healthcare compliance risks are medical coding and billing. Enforcement agencies and whistleblowers are increasingly scrutinizing modifier usage, and because of that compliance programs should be as well. The hospital ultimately settled and agreed to pay $3.3

Compliance 52

Compliance Medicare Medicare Overpayments 52

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

Hall Render

JUNE 30, 2023

Report: Amazon Pauses 50-State Virtual Care Service Expansion UnitedHealth acquires Amedisys for $3.3B MedStar Transport Celebrates 40 years of service C. MedStar Transport Celebrates 40 years of service C. Here’s why. after home health provider reneges on Option deal Will the doctor see you now?

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

Healthcare Law Blog

MARCH 2, 2023

Effective March 1 st , certain providers choosing to self-disclose Stark Law violations must use forms updated by the Centers for Medicare & Medicaid Services (“CMS”). Once CMS acknowledges receipt of a provider’s SRDP submission, the provider’s obligation to report and return overpayments within 60 days is suspended. See 42 C.F.R.

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Overpayments Overpayment Medicare Medicare 52

AIHC

MARCH 28, 2022

The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.

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Medicare Medicare Compliance Governance 52

Medisys Compliance

MARCH 7, 2022

Inaccurate information in the chart, especially when carried forward from a previous service date or entry without necessary editing, often does not afford an auditor the ability to understand if you needed to see that patient, perform that test, order that script, etc. Per CMS, medical necessity is the overarching criterion for payment.

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Medical Billing Medical Billing Outsourcing Overpayments Overpayment 52

AIHC

MARCH 22, 2022

To get the most accurate picture of your practice’s financial standing, base your calculations on the actual age of the claim, i.e., the date of service , not the date on which the claim was filed or when it changes hands from one financially responsible party to another (primary insurance to secondary insurance; insurance to patient).

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Overpayments Overpayment Compliance Medicare 52