Healthcare Compliance Blog

JUNE 9, 2022

Those claims were for presumptive and definitive Urine Drug Tests (UDTs) that were not medically reasonable or necessary and were not used to aid in the diagnosis and treatment of patients. Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate.

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US Department of Health and Human Services Overpayments Overpayment Medicare 59

Verisys

FEBRUARY 1, 2022

All individuals and organizations that meet the definition of healthcare provider as described in 45 CFR 160.103 that conduct transactions or use health records that fall under HIPAA regulations are required to obtain an NPI. Tracking actions to a standardized identifier provides transparency that can identify and impede fraud.

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Healthcare Law Blog

MAY 16, 2022

On April 29, 2022 , the Centers for Medicare and Medicaid Services (“CMS”), issued the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (the “Final Rule”). Refining Definition for Fully Integrated and Highly Integrated D-SNPs (§§ 422.2 and 422.107).

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Verisys

DECEMBER 29, 2024

The Centers for Medicare & Medicaid Services (CMS) oversees the issuance and regulation of NPI numbers, ensuring providers meet accountability standards. This requirement improves the efficiency and quality of Medicare, Medicaid, and other state and federally funded healthcare programs. Who Needs an NPI?

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Health Care Law Brief

JUNE 20, 2023

The District and the Seventh Circuit Endorsed a Pure Objective Reasonableness Standard for FCA Scienter In this case, the relator alleged that certain pharmacies, among other things, misreported their pricing of certain drugs covered by Medicare and Medicaid.

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HIPAA Journal

JULY 4, 2024

Due to concerns that the cost of the reforms would be passed onto plan members and employers, and that this would negatively impact tax revenues, Congress added a second Title to HIPAA – “Preventing Health Care Fraud and Abuse; Administrative Simplification”. The measures in Title II were intended to neutralize the cost of the reforms.

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Hall Render

FEBRUARY 14, 2025

The Centers for Medicare & Medicaid Services (CMS) recently finalized a rule (Final Rule) that expands its ability to impose a Provisional Period of Enhanced Oversight (PPEO) on providers, including post-acute providers, reactivating their Medicare enrollment.

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Health Law RX

JULY 18, 2023

The IB Rule, among other things, promulgated regulations further defining what information blocking is and establishing reasonable and necessary activities that do not constitute information blocking, i.e., exceptions to the definition of information blocking. The OIG anticipates working closely with ONC to make these threshold assessments.

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Provider Trust

MAY 17, 2022

In this post, we’ll break down the definition of healthcare vendors and summarize the most important and impactful laws and regulations that apply to vendors and the healthcare organizations that contract with them. So what does that mean for your healthcare organization’s compliance program? How to ensure vendor compliance.

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Compliancy Group

JANUARY 3, 2024

This is why a regular review of these contracts is essential so that providers and administrators can clear up uncertainties in the terms or conditions, remain compliant, and ensure the payer is engaging in fair practices.

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Health Law Advisor

APRIL 10, 2023

This distinction is relevant for applying the Preventive Care Exception to the Beneficiary Inducements CMP and may allow for a greater variety of incentives to be given to Medicare and Medicaid beneficiaries when the other requirements of that exception are met.

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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. 405.986) or “reliable evidence” of fraud or “similar fault” (as defined in 42 C.F.R. Parts 417, 422, 423, 455, and 460.

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Hall Render

MAY 9, 2022

In connection with the COVID-19 public health emergency (the “PHE”), and the expanded coverage of telehealth services by Medicare and state Medicaid programs in response thereto, the FQHC received grant funding from the Federal Communications Commission and a local charity to purchase approximately 3,000 smartphones.

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YouCompli

DECEMBER 19, 2023

Users are encouraged to use the electronic version, to allow access to hyperlinked definitions and resource documents. Exclusions (page 26) : OIG recommends that any entity participating in the federal Medicaid program should check the state Medicaid program exclusion list for each applicable state.

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Innovaare Compliance

AUGUST 24, 2023

To ensure good stewardship of the Medicare Trust Fund, the Centers for Medicare & Medicaid Services (CMS) perpetually makes changes to improve various aspects of the program – quality of care, health equity and payment methodology, to name a few.

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Medicare Medicare Fraud Medicaid 52

AIHC

SEPTEMBER 5, 2023

Most private insurers and Medicaid cover telebehavioral health care, but check for reimbursement restrictions and obtain professional coding and billing guidance to avoid overpayment situations. Store-and-forward is less commonly reimbursed by Medicare and Medicaid programs. This includes understanding various fraud and abuse laws.

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Hall Render

DECEMBER 11, 2024

The Proposed Rule would codify changes made by the Medicaid Services Investment and Accountability Act of 2019 (MSIAA), that added exclusion authorities related to misclassification and false information about outpatient drugs.

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AIHC

APRIL 10, 2024

HIPAA and HITECH is for all health care organizations falling under the definition as a Covered Entity, from solo practices to larger clinics and hospital medical networks to health plans and clearinghouses. Does your organization have materials for patient education and risks of identity theft and medical fraud?

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YouCompli

NOVEMBER 29, 2023

Users are encouraged to use the electronic version, to allow access to hyperlinked definitions and resource documents. Exclusions (page 26) : OIG recommends that any entity participating in Medicaid should check the state Medicaid program exclusion list for each applicable state.

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Healthcare Law Blog

MAY 11, 2023

Review of the Proposed Arrangement Under Federal AKS At a high level, the OIG concluded that the Arrangement presents a minimal risk of fraud and abuse under the AKS. Finally, the OIG noted that the listed safeguards set forth by the Companies reduce the risk of fraud and abuse.

Medicare 52

Medicare Medicare Fraud Compliance 52

Provider Trust

MAY 18, 2022

As referenced in our recent post on definitions and regulations for healthcare vendors, the HHS Office of Inspector General Exclusions Program mandates that healthcare organizations refrain from doing business with “excluded or sanctioned” individuals or entities, which includes your organization’s network of vendors.

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Healthcare Law Today

JANUARY 2, 2023

As written, the proposed rule would remove the existing “reasonable diligence” standard for identification of overpayments, and add the “knowing” and “knowingly” FCA definition. The FCA is a fraud statute, requiring intent. Potential Impact.

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Overpayments Overpayment ACA Medicare 52

Hall Render

NOVEMBER 15, 2023

Billing for Advanced Practice Professionals (“APPs”) has been a challenging area for providers and practitioners because of different and changing Medicare, Medicaid and state law requirements. The Arrangement contains safeguards that lower the risk of fraud and abuse under the federal AKS.

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Hall Render

JANUARY 11, 2023

Federal Food, Drug, and Cosmetic (“FD&C”) Act – If an app includes a software function that meets the definition of a medical device under section 201(h) of the FD&C Act, the app may be subject to regulatory oversight by the FDA.

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Hall Render

NOVEMBER 28, 2023

On November 1, 2023, the Centers for Medicare & Medicaid Services (“CMS”) posted a pre-publication copy of the Calendar Year (“CY”) 2024 Home Health Prospective Payment System Rate Update Final Rule (“2024 Final Rule”), which has since been filed in the Federal Register. Even developing this data may not be sufficient. Managing Employee.

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AIHC

AUGUST 8, 2023

I am a Certified Internal Healthcare Fraud Auditor (CIFHA). Both the American Society for Quality (ASQ) and Centers for Medicare and Medicaid Services (CMS) recognize this tool’s usefulness in root cause analysis (RCA). Use as many as will definitively detail the problem statement.

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Compliance Fraud Medicaid Medicaid 52

AIHC

APRIL 10, 2024

HIPAA and HITECH is for all health care organizations falling under the definition as a Covered Entity, from solo practices to larger clinics and hospital medical networks to health plans and clearinghouses. Does your organization have materials for patient education and risks of identity theft and medical fraud?

Compliance 52

Compliance US Department of Health and Human Services HIPAA Electronic Medical Records 52

Hall Render

JULY 12, 2023

489.18 (the traditional definitions of CHOW) is necessary to trigger this “36-month rule.” Under 42 CFR § 424.550(b)(1), neither a 100% ownership transfer nor a change that qualifies as a CHOW under 42 C.F.R.

Medicare 40

Medicare Medicare Nursing Homes Fraud 40

C&M Health Law

FEBRUARY 16, 2021

On November 13, 2020, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule , demonstrating long-awaited efforts to streamline the regulatory framework governing the Medicaid and Children’s Health Insurance Program (“CHIP”) managed care programs. Standard Contract Requirements/Coordination of Benefits.

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Healthcare Law Blog

MARCH 3, 2023

This surge was facilitated, in part, by certain flexibilities authorized by the Centers for Medicare & Medicaid Services in its response to the public health emergency (“PHE”) declared in March of 2020 and which was repeatedly renewed until now. On January 30, 2023, President Joe Biden announced that the PHE would end on May 11, 2023.

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AIHC

FEBRUARY 16, 2024

Because aspiration pneumonia is excluded from Centers for Medical & Medicaid Services (CMS) pneumonia mortality scores, the implicit conclusion is that a hospital can improve its public rating by coding its oldest and sickest patients with pneumonia as having aspiration pneumonia. First, we need to look at exactly what happened.

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

AIHC

FEBRUARY 16, 2024

Because aspiration pneumonia is excluded from Centers for Medical & Medicaid Services (CMS) pneumonia mortality scores, the implicit conclusion is that a hospital can improve its public rating by coding its oldest and sickest patients with pneumonia as having aspiration pneumonia. First, we need to look at exactly what happened.

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

Bill of Health

FEBRUARY 10, 2023

That is why the ACA’s Medicaid expansion doesn’t exist in 11 states , why the penalties for failing to have insurance under the “individual mandate” has been set to $0.00. Or an extension of the doctrine of public fraud? Witness the success of environmental policy litigation in the ’70s. Maybe some form of public nuisance litigation?

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Healthcare Law Blog

NOVEMBER 16, 2023

Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”) will publish a final rule requiring Medicare skilled nursing facilities (“SNFs”) and Medicaid nursing facilities (“Facilities”) to provide more detailed ownership, managerial and other information on Form CMS-855A (the “Final Rule”). [1]

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Innovaare Compliance

OCTOBER 6, 2022

According to the Centers for Medicare & Medicaid Services (CMS), enrollment in MAPD keeps rising. The purpose of these audits is to evaluate a plan sponsor’s efforts to prevent, detect, and correct fraud, waste, and abuse (FWA) in the Medicare Part C and Part D programs.

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Healthcare IT Today

NOVEMBER 13, 2024

The following is a guest article by Crystal Campbell, Director Out-of-State Medicaid at Aspirion For healthcare providers, managing out-of-state (OOS) Medicaid claims can feel like traversing a regulatory minefield. This variation creates significant hurdles for hospitals treating OOS Medicaid patients.

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Hall Render

JUNE 28, 2024

Pritzker joins health officials, advocates to redouble HIV/AIDS prevention efforts Illinois Man Indicted on Several Fraud Charges Linked to COVID Pandemic INDIANA Franciscan Alliance sued by Indy physician for breach of contract, interfering in practice Hamilton County hospital surge comes amid closings elsewhere IU Health’s $2.3B

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