HIPAA Journal

NOVEMBER 21, 2022

million being defrauded from Medicaid, Medicare, and private health insurance programs. The payments were intended for hospitals for providing covered medical services. The arrests were related to a series of scams that spoofed hospital email accounts. million, and $6.4

Medicaid 81

Medicaid Medicaid Medicare Medicare 81

Compliancy Group

APRIL 17, 2024

Office of Inspector General (OIG) in the Department of Health and Human Services (DHHS) oversees efforts in the healthcare sector to identify, reduce, and prevent incidents of fraud, waste, and abuse of funds from programs like Medicare. Medicare Advantage (M.A.): and cybersecurity threats. Organizations using M.A.

Compliance Officers 52

Compliance Officers Compliance Medicare Medicare 52

Healthcare Compliance Blog

MAY 19, 2022

An acute care hospital in Oklahoma has paid over $1.1 million to settle allegations that it violated the False Claims Act by submitting false claims to Medicare. Throughout the investigation, the hospital cooperated with the above entities. The hospital agreed to pay the United States $1,151,770.50 to resolve the claims.

US Department of Health and Human Services 59

US Department of Health and Human Services Hospitals Medicare Medicare 59

Pharmacy Law Blog

FEBRUARY 13, 2018

On November 22, 2017, a Florida woman who was accused of a $45 million Medicare fraud, received a six-and-a-half-year prison sentence, following a 2016 U.S. Supreme Court decision in her case holding that the government could not freeze untainted assets. Indest III, J.D., Board Certified by The Florida Bar in Health Law.

Fraud 40

Fraud Medicare Medicare Governance 40

Provider Trust

JANUARY 25, 2024

This report helps HHS fulfill its mission to improve the health and well-being of Americans while also providing suggestions for how healthcare organizations can stay ahead of the curve to avoid and combat fraud, waste, and abuse. With Medicaid, the challenges are equally formidable.

Fraud 52

Fraud Medicaid Medicaid Medicare 52

MedTrainer

JULY 28, 2023

Earlier this year, an in-depth OIG investigation resulted in a six-day trial of a former Louisiana health clinic CEO , who was ultimately convicted of Medicaid fraud and sentenced to 82 months in federal prison. Medicare/Medicaid Compliance Reviews. The OIG performs regular compliance reviews of Medicare and Medicaid providers.

Fraud 98

Fraud Compliance Medicaid Medicaid 98

Kaiser Health News

NOVEMBER 11, 2021

Finding the best private Medicare drug or medical insurance plan among dozens of choices is tough enough without throwing misleading sales tactics into the mix. The problems are especially prevalent during Medicare’s open-enrollment period, which began Oct. “You’re not from Medicare,” Heimer told her.

Medicare 144

Medicare Medicare Doctors Fraud 144

AIHC

MAY 31, 2022

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. To combat fraud and abuse, all levels within a medical practice, hospital or health care organization must know how to protect the organization from engaging in abusive practices and violations of civil or criminal laws.

Fraud 52

Fraud Compliance Officers Compliance Medicare 52

Verisys

FEBRUARY 14, 2024

Governance, Risk Management, and Compliance (GRC) in healthcare is an integrated approach that helps healthcare organizations manage their overall governance, enterprise risk management, and comply with regulatory requirements in a cohesive and aligned manner. What is healthcare data governance? What is GRC in Healthcare?

Governance 52

Governance Compliance Regulatory Compliance Compliance Framework 52

MedTrainer

FEBRUARY 12, 2024

government collected $2.2B Knowingly or falsely claiming monies from federal programs such as Medicare and Medicaid has cost healthcare entities $72B since 1986. in settlements and judgments from healthcare organizations accused of filing false claims in fiscal 2022.

Compliance 52

Compliance Fraud Medicaid Medicaid 52

AIHC

NOVEMBER 29, 2023

Medicare changed reimbursement methodology in the 1980s by introducing Relative Value Units (RVUs) and the RBRVS (Resource-Based Relative Value System) for physician reimbursement. Hospital reimbursement also changed. As the cost of providing care grew, payers started instituting methods to curb expenses and how claims were paid.

Medicare 59

Medicare Medicare Medicaid Medicaid 59

YouCompli

JULY 26, 2023

Fraud, waste, and abuse (FWA) associated with telehealth services existed before COVID-19, but it significantly increased during the pandemic. The audit also identified 1,714 providers whose billing for telehealth services during the first year of the pandemic posed a high risk to Medicare. million in Medicare fee-for-service payments.

Fraud 52

Fraud Compliance Medicare Medicare 52

AIHC

NOVEMBER 29, 2023

Medicare changed reimbursement methodology in the 1980s by introducing Relative Value Units (RVUs) and the RBRVS (Resource-Based Relative Value System) for physician reimbursement. Hospital reimbursement also changed. As the cost of providing care grew, payers started instituting methods to curb expenses and how claims were paid.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

MedTrainer

JANUARY 12, 2024

Healthcare compliance is the process of following the laws, regulations, and ethical standards that govern the healthcare industry. Here are some of the key organizations involved in regulating healthcare compliance: Centers for Medicare & Medicaid Services (CMS): CMS is a federal agency within the U.S.

Compliance 52

Compliance Fraud Medicaid Medicaid 52

Healthcare IT News - Telehealth

JULY 16, 2020

Now, the question becomes : How many of those changes, particularly regarding temporary waivers issued by the Centers for Medicare and Medicaid Services, will become permanent? Among other provisions, the act would eliminate most geographic and originating site restrictions on the use of telehealth in Medicare. " asked Leary.

COVID-19 135

COVID-19 Medicare Medicare Governance 135

Hall Render

FEBRUARY 25, 2022

Under the Donors’ agreement with the Children’s Hospital (“Agreement”), the Hospital and the Fund would pay all out-of-pocket costs incurred by qualified families for their child’s medical care in the cancer, cardiac or neurosurgical programs, referred to as the “Initial Supported Programs.”

Fraud 40

Fraud Hospitals Medicare Medicare 40

Health Law Advisor

FEBRUARY 10, 2023

The total recoveries in fraud cases brought with respect to the health care and life sciences industries fell to the lowest level since 2009. billion was recovered in qui tam cases in which the government declined to intervene. By contrast, $777 million was recovered in cases where the government intervened or otherwise pursued.

Fraud 52

Fraud COVID-19 Governance Medicaid 52

Verisys

DECEMBER 5, 2023

For the medical staff services team at a hospital to properly verify a healthcare practitioner’s credentials, dozens of primary sources must be contacted directly, and those primary source organizations must then verify the credentials of the practitioner in question. The policy issuer for malpractice insurance verifies insurance coverage.

Governance 52

Governance Licensing Malpractice Medicaid 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.

US Department of Health and Human Services 52

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

Hall Render

MARCH 20, 2023

Scott advises health care organizations on a broad range of regulatory and transactional matters, with a particular focus on issues relating to value-based care, fraud and abuse and the implementation of innovative health care delivery and payment models. from the University of North Carolina School of Law.

Fraud 40

Fraud Medicare Medicare Medicaid 40

MedTrainer

JUNE 29, 2023

Healthcare is an industry governed by countless regulations. While it can sometimes feel like there’s dozens and dozens of different healthcare standards, the biggest governing policies really boil down to four major regulations. Why are Healthcare Regulations Important? Healthcare regulations are crucial for several reasons.

Fraud 52

Fraud HIPAA Compliance Governance 52

MedTrainer

OCTOBER 4, 2023

These regulations and laws help maintain patient confidentiality, ensure quality care, and prevent fraud and abuse within the healthcare industry. These requirements are designed to protect patient rights, privacy, and safety, as well as to prevent fraud, abuse, and other improper practices within healthcare organizations.

Compliance 52

Compliance Fraud HIPAA Governance 52

MedTrainer

MARCH 14, 2024

As the Centers for Medicare and Medicaid Services outlines, privileging isn’t required for every healthcare provider but is a requirement for those conducting medical services within a hospital or ambulatory surgery center (ASC). Courtesy: This is when a hospital occasionally allows a provider to admit and treat a patient.

Malpractice 52

Malpractice Licensing Hospitals Compliance 52

AIHC

APRIL 5, 2022

Audit Coding, Billing and Documentation for Accuracy Insurance carriers and government contractors have the authority to review any claims at any time. 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

MedTrainer

JANUARY 12, 2024

Healthcare compliance is the process of following the laws, regulations, and ethical standards that govern the healthcare industry. Medicare and Medicaid (1960s): The introduction of government-funded healthcare programs brought about increased scrutiny and regulation. What is Healthcare Compliance?

Compliance 52

Compliance HIPAA Telemedicine ACA 52

Hall Render

FEBRUARY 4, 2022

Of that, $5 billion relates to health care fraud involving drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians. Health Care Fraud Actions. ” Medicare Part C. ” Medicare Part C. Boynton of the DOJ Civil Division.

Fraud 40

Fraud Governance Medicare Medicare 40

Healthcare IT News - Telehealth

JUNE 8, 2022

But even now, hospitals and health systems should be preparing proactively to meet the regulatory demands of a post-PHE future. Additionally, several telehealth flexibilities (that generally expand Medicare coverage for telehealth services) have been extended 151 days (about five months) beyond the termination of the HHS PHE.

US Department of Health and Human Services 176

US Department of Health and Human Services Compliance Overpayments Overpayment 176

YouCompli

APRIL 13, 2022

But tactics common in other industries might be considered illegal beneficiary inducements in healthcare, especially for beneficiaries of federal programs like Medicare or Medicaid. Co-pay waivers,” “insurance only billing,” “Medicare accepted as payment in full,” and “free gift for new patients” are just some examples.

Medicare 40

Medicare Medicare Governance Compliance 40

YouCompli

DECEMBER 7, 2022

These exclusions are generally related to criminal activity like fraud or healthcare-related misconduct. Felony convictions for other healthcare-related fraud, theft, or other financial misconduct. A Puerto Rican hospital settled for $105,000 for allegedly hiring an excluded individual as a medical utilization director.

Fraud 52

Fraud US Department of Health and Human Services Compliance Medicaid 52

Provider Trust

MAY 17, 2022

Our research shows, on average, a hospital with 1,000+ employees also contracts with and/or relies upon an even larger network of vendors. It handles Protected Health Information and processes and stores such data for a hospital. Vendor Y is a supplier of surgical instruments to a hospital.

Compliance 52

Compliance Medicare Medicare Due Diligence 52

Compliancy Group

AUGUST 31, 2023

Healthcare compliance laws play a vital role in safeguarding patients’ rights, preventing fraud and abuse, and maintaining the integrity of healthcare systems. Let’s delve into the importance of healthcare compliance laws and regulations, their impact on providers and organizations, and the guidelines governing their implementation.

Compliance 52

Compliance Compliance Officers Fraud Compliance Framework 52

Verisys

MARCH 1, 2022

For the medical staff services team at a hospital to properly verify a healthcare practitioner’s credentials, dozens of primary sources must be contacted directly, and those primary source organizations must then verify the credentials of the practitioner in question. Government and Non-Government Sources. And the list goes on.…

Governance 52

Governance Licensing Malpractice Medicaid 52

Verisys

NOVEMBER 14, 2023

The Importance of Thorough Credentialing The credentialing process for hospitals and health systems prioritizes in-depth research and meticulous accuracy, which means that it is not a speedy process, often taking from 90 to 120 days to complete. However, verifying a provider’s credentials is essential.

Licensing 52

Licensing Medicaid Medicaid Governance 52

Verisys

FEBRUARY 23, 2022

As government agencies and national regulatory organizations pass more regulations and the need for healthcare services grows, healthcare compliance officers (HCOs) are more important than ever. Facilities increasingly rely on healthcare compliance officers (HCOs) to bridge the gap between government regulation and daily operations.

Compliance Officers 52

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

MedTrainer

NOVEMBER 6, 2023

While specific compliance requirements vary depending on the type of facility — from large hospitals and surgery centers to clinics and nursing homes — having a well-structured compliance plan is essential for all medical settings. But what exactly is a compliance plan in healthcare, and why is it so crucial?

Compliance 52

Compliance Fraud Nursing Homes Governance 52

Healthcare Law Blog

JUNE 27, 2022

22-07 which evaluated the risk of fraud and abuse under the federal anti-kickback statute (“AKS”) posed by an arrangement involving physician-ownership of a medical device company. The opinion identified six characteristics of the arrangement which greatly reduced the risk of fraud and abuse. Transparency Regarding Ownership Interest.

Fraud 52

Fraud Hospitals Medicare 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. This standard was interpreted and applied differently by various Medicare contractors and was difficult to review/audit.

Medicare 40

Medicare Medicare Medicaid Medicaid 40