Document, Fraud and Overpayment - Health Care Compliance Brief

Preventing Genetic Testing Fraud: 5 Actions for Health Plans

Healthcare IT Today

MAY 5, 2023

The following is a guest article by Erin Rutzler, Vice President of Fraud, Waste, and Abuse at Cotiviti In Delaware, more than 250 Medicare patients underwent unnecessary genetic testing based on telehealth consultations that often lasted less than two minutes— costing Medicare thousands of dollars per patient. In 2021, a U.S.

Fraud

Fraud Medicare Medicare Overpayments

Part 3: Audit Documentation to Avoid Potential Appeal Consequences

AIHC

APRIL 5, 2022

Only appeal claims when you have evidence and supporting documentation to substantiate your right to payment. Audit Coding, Billing and Documentation for Accuracy Insurance carriers and government contractors have the authority to review any claims at any time. However, it also includes documentation of a supporting diagnosis.

Fraud

Fraud Compliance Medicare Medicare

Navigating CMS UPIC Audits: A Guide for Healthcare Organizations

Compliancy Group

FEBRUARY 7, 2024

CMS UPIC audits are designed to identify and prevent fraud, waste, and abuse within Medicare and Medicaid, ensuring that federal funds are used appropriately and that the services billed for are actually provided and are medically necessary. Given their significant impact, healthcare organizations must take UPIC audits seriously.

Fraud

Fraud Compliance Medicare Medicare

Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program

Healthcare Law Blog

FEBRUARY 3, 2023

OMIG’s new Compliance Program Guidance outlines several best practices and provides examples of documentation that OMIG believes Medicaid required providers should maintain to demonstrate that the they have adopted, implemented and maintain effective compliance programs that meet each of the 7 elements specified in the regulations.

Medicaid

Medicaid Medicaid Compliance Overpayments

2024 Final Rule: CMS Announces More Changes to Medicare Advantage but Declines to Reform the “60 Day Rule”

Health Care Law Brief

APRIL 12, 2023

405.986) or “reliable evidence” of fraud or “similar fault” (as defined in 42 C.F.R. 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. 3729(b)(1)(A) of the False Claims Act (“FCA”). See Proposed Rule at 79559.

Medicare

Medicare Medicare Overpayments Overpayment

OIG Posts False Claims Act Settlements for FY 2022 Q1–Q4 on the Risk Spectrum

Med-Net Compliance

OCTOBER 21, 2022

The government’s primary civil tool for addressing healthcare fraud is the FCA. The risk categories are described as follows: Highest Risk—Exclusion: Parties that the OIG determines present the highest risk of fraud will be excluded from Federal healthcare programs to protect those programs and their beneficiaries.

Fraud

Fraud Compliance Medicare Medicare

Department of Justice (DOJ) Evaluation of Corporate Compliance Programs

Compliancy Group

FEBRUARY 2, 2024

Tangible indicators of sufficient resources and effort include adequate staff assigned to conduct audits and document and analyze the results of the program’s efforts. The DOJ will also determine if there is sufficient communication to employees informing them about the compliance program and garnering commitment to its mission.

Compliance

Compliance Overpayments Overpayment Compliance Officers

The Power of a Quality Review: Your Best Defense Against OIG Audits

Healthcare IT Today

FEBRUARY 2, 2023

It has given every indication that it intends to investigate fraud, waste, and abuse more robustly in the foreseeable future. The Justice Department has joined the fraud case against one large national insurer. Missed conditions: If a member has a condition that is being treated or monitored, it must be documented.

Medicare

Medicare Medicare Medicaid Medicaid

Pennsylvania Man Excluded from All Federal Healthcare Programs for 22 Years

Healthcare Compliance Blog

JUNE 9, 2022

In March of 2022, in a related matter, the man pleaded guilty to Healthcare Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the US Department of Health and Human Services between 2016 and 2020. Document that the trainings occurred and place in each employee’s education file.

US Department of Health and Human Services

US Department of Health and Human Services Medicare Medicare Overpayments

Retrieving Billions in Overpayments by CMS

Healthcare IT Today

FEBRUARY 17, 2023

This article focuses on the relatively young technologies that enable CMS to uncover overbillings, whether they be errors or fraud. Challenges of Investigating Overpayments Undeserved payments are needles lurking in the haystack of 135 million Americans enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

Overpayments

Overpayments Overpayment COVID-19 Medicare

OIG Issues Updated General Compliance Program Guidance: Overview of Key Elements & Changes

C&M Health Law

DECEMBER 18, 2023

OIG also specifically calls out the growing presence of private equity and other forms of private investment in health care and recommends that such investors scrutinize their operations and oversight to ensure compliance with fraud and abuse laws and the delivery of high-quality care for patients.

Compliance

Compliance Compliance Officers Governance Overpayments

Introduction to Telebehavioral Health

AIHC

SEPTEMBER 5, 2023

Keep in mind coding and documentation is extremely important for psychiatric services – consider registering for the Psychiatric Compliance – coding & documentation short course offered by the American Institute of Healthcare Compliance. This includes understanding various fraud and abuse laws.

COVID-19

COVID-19 Telemedicine Compliance Informed Consent

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010

CMS.gov

NOVEMBER 16, 2018

Fraud, waste, & abuse. Improper payments are not necessarily measures of fraud, but instead are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements. These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred.

Medicare

Medicare Medicare Overpayments Overpayment

Health Provider News

Hall Render

MAY 10, 2024

Health Policy Commission still missing key document in Steward sale to Optum Local obesity drug developer lands deal worth up to $600M with Novo Nordisk Mass. Health Policy Commission still missing key document in Steward sale to Optum Local obesity drug developer lands deal worth up to $600M with Novo Nordisk Mass.

Nursing Homes

Nursing Homes Nurses Hospitals Medicaid

Preparing for Payer Coding Audits

Medisys Compliance

MARCH 7, 2022

These are usually just innocuous mistakes that do not represent any intent to commit billing fraud. You want unique documentation for each encounter, and it should stand out in your progress note. In the unfortunate event when you receive such overpayment demand letters, don’t acquiesce without conducting an analysis first.

Medical Billing

Medical Billing Medical Billing Outsourcing Overpayments Overpayment

Part 2: Understanding How Payers Deny Claims

AIHC

MARCH 28, 2022

This includes any documentation submitted with the claim or through an additional documentation request. Special review of documentation, payer guidelines and often appealing the claim is required to obtain payment. Special review of documentation, payer guidelines and often appealing the claim is required to obtain payment.

Medicare

Medicare Medicare Compliance Governance

Health Provider News – October 7, 2022

Hall Render

OCTOBER 7, 2022

Judge orders Anthem to face lawsuit over alleged Medicare overpayments. Over 50% of Text in EHR Notes is Duplicate Clinical Documentation. Local Jax health care provider settles fraud allegations by paying $700,000. Million Health Care Fraud. How tight nursing home capacity is bottlenecking hospital operations.

COVID-19

COVID-19 Nurses Nursing Homes Hospitals