AIHC

MAY 28, 2025

A coding algorithm that misclassifies a procedure or service can lead to overpayments and potential allegations of fraud. Organizations that invest in cross-disciplinary governance, risk management, and regulatory alignment will be best positioned to harness the promise of AI while safeguarding their mission and integrity.

Compliance 45

Compliance Overpayments Overpayment FDA 45

Health Law RX

MARCH 30, 2023

Setting aside the incalculable impact that litigation can have on business operations, the statute itself anticipates repayment of the proven overpayment, treble damages, and exposure to a civil statutory penalty equal to a range between $13,508 and $27,018 per false claim. This is the reality for a medical company in Minnesota.

Overpayments 52

Overpayments Overpayment Fraud Governance 52

AIHC

SEPTEMBER 30, 2024

This was originally mandated by the Centers for Medicare & Medicaid Services (CMS) back in 1997 and implemented in 2004. The OIG made the following recommendations to Humana: Refund to the Federal Government the $6.8 HCC coding relies on ICD-10-CM coding to assign risk scores to patients.

Overpayments 52

Overpayments Overpayment Compliance Medicare 52

The Health Law Firm

FEBRUARY 20, 2018

million to settle a whistle blower lawsuit alleging its pharmacies caused federal health programs to overpay for prescription drugs by not telling the government about discounted prices. The department store chain withheld certain information from Medicare Part D, Medicaid and Tricare, the Department of Justice (DOJ) said.

Overpayments 40

Overpayments Overpayment Medicaid Medicaid 40

AIHC

FEBRUARY 17, 2025

There are also self-reporting mechanisms in place to report overpayments on the OIG website ( Self-Disclosure ) and Self-Referral Disclosure for voluntary self-reporting of overpayments on the Centers for Medicare and Medicaid Services’ (CMS’) website. The list of terms and definitions used throughout are below for reference.

Fraud 52

Fraud Compliance Overpayments Overpayment 52

AIHC

FEBRUARY 17, 2025

There are also self-reporting mechanisms in place to report overpayments on the OIG website ( Self-Disclosure ) and Self-Referral Disclosure for voluntary self-reporting of overpayments on the Centers for Medicare and Medicaid Services (CMS) website. The list of terms and definitions used throughout are below for reference.

Fraud 52

Fraud Compliance Overpayments Overpayment 52

Verisys

MAY 15, 2025

Understanding Payment Integrity in Claims Processing Payment integrity (PI) in healthcare is the process by which payors ensure that health plan claims are processed and paid accurately while reducing risks of fraud, overpayment, or underpayment. Ultimately, these can cause claims denials, underpayment, or overpayment of claims.

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Overpayments Overpayment Fraud Medical Billing 52

Florida Health Care Law Firm

DECEMBER 2, 2021

As described on the OIG website, “Self-disclosures give persons the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.”. Any overpayment retained after this period may create liability under the Civil Monetary Penalties Law and the False Claims Act.

Overpayments 40

Overpayments Overpayment Fraud Medicare 40

YouCompli

FEBRUARY 22, 2023

Most federal healthcare payors such as Medicare and Medicaid reimburse most providers on a prospective basis. Allegedly, the facility also failed to fully reimburse the government for its receipt of these outlier payments after it became aware of the issue. Return illegitimate reimbursement and overpayments quickly.

Compliance 52

Compliance US Department of Health and Human Services Overpayments Overpayment 52

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. 6] Improper payments can be overpayments and underpayments. in 2021 to $170.00

Medicare 52

Medicare Medicare Overpayments Overpayment 52

HIPAA Journal

MARCH 30, 2022

However, when HIPAA was passed, the standards governing health care data, patients´ rights, and the flow of information were still several years away. It was only when the provisions of a companion bill ( HR.3103 It was not until 2002 that the Privacy Rule was published, and 2003 that the Security Rule was published.

HIPAA 138

HIPAA Fraud Health Insurance Health Care Reform 138

Med-Net Compliance

OCTOBER 21, 2022

The government’s primary civil tool for addressing healthcare fraud is the FCA. Most of these cases are resolved through settlement agreements in which the government alleges fraudulent conduct and the settling parties do not admit liability.

Fraud 59

Fraud Compliance Medicare Medicare 59

HIT Consultant

MARCH 20, 2024

The Centers for Medicare and Medicaid Services (CMS) estimated that for payment year 2018 alone , it will recover $428.4 The Centers for Medicare and Medicaid Services (CMS) estimated that for payment year 2018 alone , it will recover $428.4 million (net) and $4.7 billion from 2023 through 2032, including extrapolation effects.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

Health Law RX

NOVEMBER 9, 2021

The updated SDP makes several important revisions and clarifications that directly impact providers and suppliers who seek to self-disclose potential violations of healthcare fraud statutes to the government. The likelihood that a self-discloser would be required to pay a damages multiplier greater than 1.5

Fraud 52

Fraud Overpayments Overpayment Governance 52

YouCompli

SEPTEMBER 27, 2023

Enforcement agencies like to “follow the money,” so to speak, and they often find it in medical claims submitted to government payors such as Medicare and Medicaid.  She also claimed the hospital failed to reimburse payors for overpayment stemming from these improperly coded claims.

Compliance 52

Compliance Medicare Medicare Overpayments 52

Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 Retrieved from [link] Centers for Medicare & Medicaid Services. Retrieved from [link] Centers for Medicare & Medicaid Services. billion in healthcare fraud judgments and settlements. 2021, January 15).

Fraud 52

Fraud Compliance Health Insurance Medicaid 52

Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 Retrieved from [link] Centers for Medicare & Medicaid Services. Retrieved from [link] Centers for Medicare & Medicaid Services. billion in healthcare fraud judgments and settlements. 2021, January 15).

Fraud 52

Fraud Health Insurance Medicaid Medicaid 52

YouCompli

SEPTEMBER 13, 2023

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. There also should be education on other important, but less recognizable, types of Medicare or Medicaid fraud.

US Department of Health and Human Services 52

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

AIHC

OCTOBER 23, 2024

Defined Criteria” are standards identified in advance and approved for use in a specific audit, generally set by government rules, regulations or government agencies, such as CMS or pre-approved by the governing board of your organization. Corrective action includes refunding overpayments revealed during the audit.

Compliance 52

Compliance Overpayments Overpayment Medicaid 52

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.

Compliance 40

Compliance Licensing Nurses Medicaid 40

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 is also called “store-and-forward telemedicine.”

COVID-19 59

COVID-19 Telemedicine Informed Consent Compliance 59

C&M Health Law

DECEMBER 18, 2023

OIG specifically references the United States Sentencing Commission’s Guidelines that require that an entity’s “governing authority shall be knowledgeable about the content and operation of the compliance and ethics effectiveness of the compliance and ethics program.”

Compliance 52

Compliance Compliance Officers Governance Overpayments 52

AIHC

MARCH 28, 2022

Government Accountability Office (GAO), improper payments have been estimated to total almost $1.7 trillion government-wide from fiscal years 2003 through 2019. Auditing and denying claims after the claims have been paid is “big money” for the government. According to the U.S.

Medicare 52

Medicare Medicare Compliance Governance 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. If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back.

Fraud 52

Fraud Medicare Medicare Compliance 52

The Health Law Firm Blog

AUGUST 23, 2022

Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals. By George F. Indest III, J.D., Board Certified by The Florida Bar in Health Law On June 15, 2022, the U.S. This came in a ruling that limits regulators’ power to control what the program pays for certain [.].

Medicare 52

Medicare Medicare Hospitals Governance 52

Hall Render

NOVEMBER 25, 2024

When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, the claim submission form includes certifications that the claimed services were provided in compliance with all applicable statutes, regulations and rules.

Nurses 40

Nurses Compliance Compliance Officers Medicare 40

The Health Law Firm Blog

NOVEMBER 18, 2023

Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals. By George F. Indest III, J.D., Board Certified by The Florida Bar in Health Law On June 15, 2022, the U.S. This came in a ruling that limits regulators’ power to control what the program pays for certain [.]

Medicare 40

Medicare Medicare Hospitals Governance 40

Kaiser Health News

JUNE 29, 2022

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday. ” The health plan required patients to have an X-ray first to prove a CT scan was needed.

Medicare 106

Medicare Medicare Governance Overpayments 106

AIHC

JUNE 4, 2025

Nursing homes must adhere to the ROPs established by the Centers for Medicare & Medicaid Services (CMS) to receive reimbursement for Medicare and Medicaid patients. The government looks at the bills as being fraudulent because the care and services were so inadequate, as if the care and services weren’t provided.

Nursing Homes 83

Nursing Homes Nurses Compliance Medicare 83

HIT Consultant

MARCH 1, 2022

In Ohio, unemployment overpayments reached $3.86 Medicaid systems are struggling as potential expansion looms Clearly, many state unemployment information systems are in dire need of upgrades. For Medicaid, the threat comes as potential expansion looms. Centers for Medicare and Medicaid Services (CMS) reimbursed states $34.3

Medicaid 52

Medicaid Medicaid COVID-19 Overpayments 52

Healthicity

JUNE 5, 2025

But the fact that skilled nursing got the first guidance, I think tells you a little bit about what the government views as their priority list for enforcement. to determine what our overpayment liability is. And we knew that industry specific stuff was coming. Skilled nursing facilities have the most recent guidance out there.

Nurses 52

Nurses Compliance Nursing Homes Compliance Officers 52

HIPAA Journal

MAY 12, 2025

For example, it is a condition of participation in Medicare and Medicaid that hospices conduct criminal background checks on all employees that have direct patient contact or access to patient records ( 42 CFR 418.114(d) ). There are also federal regulations that require background checks for healthcare employees.

Regulatory Compliance 44

Regulatory Compliance Fraud Compliance Licensing 44

Healthcare IT Today

FEBRUARY 17, 2023

government and calls for better oversight , the Centers for Medicare & Medicaid Services announced in early February that it would investigate overbilling by those plans. How can such overpayments be uncovered? public in overpayments. They expect to recoup 4.7 billion dollars through this program.

Overpayments 85

Overpayments Overpayment COVID-19 Medicare 85

Healthcare Law Blog

JANUARY 5, 2023

Just in time for the holidays, the Centers for Medicare and Medicaid Services (“CMS”) issued the Contract Year 2024 Proposed Rule for Medicare Advantage organizations (“MAOs”) and Part D sponsors (the “Proposed Rule”). We’ve summarized some of the key changes in the Proposed Rule. Comments on due February 13, 2023. Star Ratings.

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Healthcare Dive

JUNE 12, 2025

By Rebecca Pifer • May 14, 2025 Anna Moneymaker/Getty Images via Getty Images CMS expands audits to crack down on Medicare Advantage overpayments The agency said it would increase the number of MA plan audits and complete its backlog of reviews by investing in technology and growing its medical coding workforce. TechTarget, Inc.s

Overpayments 211

Overpayments Overpayment COVID-19 Licensing 211

Healthcare Dive

JUNE 12, 2025

By Rebecca Pifer • May 14, 2025 Anna Moneymaker/Getty Images via Getty Images CMS expands audits to crack down on Medicare Advantage overpayments The agency said it would increase the number of MA plan audits and complete its backlog of reviews by investing in technology and growing its medical coding workforce.

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Overpayments Overpayment COVID-19 Medicare 174

McBrayer Law Blog

JUNE 2, 2025

Posted In Centers for Medicare & Medicaid Services (CMS) , False Claims Act , Medicaid , Office of Inspector General of the United States Department of Health and Human Services (OIG) , Overpayments With the OIG’s May 30, 2025, announcement that they are seeking $454.4

Overpayments 52

Overpayments Overpayment Fraud Medicaid 52