Healthcare Law Blog

AUGUST 25, 2023

On August 21, 2023, the New York State Office of the Medicaid Inspector General (OMIG) announced updates to the Medicaid overpayment self-disclosure program, which now includes an abbreviated process for reporting and explaining overpayments that are considered routine or transactional in nature and have been already voided and adjusted.

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Overpayments Overpayment Medicaid Medicaid 52

Hall Render

JUNE 20, 2025

On May 21, 2025, the Centers for Medicare & Medicaid Services (“CMS”) announced a substantial expansion of its Risk Adjustment Data Validation (“RADV”) audit program for all Medicare Advantage (“MA”) plans. Background CMS’s recent announcement aligns with broader federal efforts to curb fraud, waste and abuse in federally funded programs.

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Medicare Medicare Overpayments Overpayment 52

Medisys Compliance

JUNE 8, 2025

In the case of Medicare, the Centers for Medicare & Medicaid Services (CMS) delegates this responsibility to the Benefits Coordination & Recovery Center (BCRC). Submitting claims in the wrong order often leads to rejections, overpayments, or audits, making accurate COB practices vital for healthcare providers.

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YouCompli

JUNE 25, 2025

Assisting Revenue with 60-Day Repayment Rule Requirements Even if an entity makes innocent billing mistakes, they have an obligation to repay the money to government third-party payers such as Medicare and Medicaid. Sometimes this is referred to as the 60-day repayment rule.

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Compliance Overpayments Overpayment Compliance Officers 52

The Health Law Firm

FEBRUARY 27, 2013

Our firm has been consulted recently by owners of different health care entities, including assisted living facilities (ALFs), group homes, home health agencies and even medical groups that had received Medicaid overpayment demands. This resulted in a Medicaid overpayment assessment.

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Innovaare Compliance

DECEMBER 14, 2023

Cigna allegedly submitted inaccurate patient diagnosis data to the Centers for Medicare & Medicaid Services (CMS), impacting payments received and raising serious compliance concerns​​. CMS’s Role and the RADV Audits Program Medicare Advantage overpayments have become alarmingly problematic in the private payer program.

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Overpayments Overpayment Medicare Medicare 52

Healthcare Law Blog

FEBRUARY 1, 2023

On January 30, 2023 , the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). case number 18-5326 , which reinstated CMS’s Overpayment Rule for MA organizations. See also Ratanasen v.

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YouCompli

FEBRUARY 4, 2025

When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, it certifies the services were provided in compliance with all applicable statutes, regulations, and rules. Even if an entity makes an isolated billing error, that entity still has an obligation to repay the overpayment to avoid False Claims Act liability.

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Nurses Overpayments Overpayment Compliance 52

Health Care Law Brief

JUNE 26, 2022

With this denial, the Overpayment Rule remains in full force and effect, and UnitedHealthcare, among other MA plans, must comply or potentially face False Claims Act (FCA) liability. The Overpayment Rule. The Overpayment Rule, set forth at 42 U.S.C. 29844, 29921 (May 23, 2014). See UnitedHealthcare Insurance Co. 3d 173 (Sep.

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Overpayments Overpayment Medicare Medicare 52

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. And, a provider is required to refund overpayments it is obliged to refund within 60 days of such identified overpayment.

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Compliancy Group

FEBRUARY 12, 2025

Using the ICPG to Maintain an Effective Compliance Program The Centers for Medicare & Medicaid Services (CMS) has issued participation requirements for nursing facilities in the Medicare and Medicaid programs (Requirements of Participation or ROPs). The ICP covers the areas listed below.

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Nurses Compliance Medicare Medicare 52

The Health Law Firm

FEBRUARY 15, 2016

Board Certified by The Florida Bar in Health On February 11, 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule which eased requirements for health care providers to return overpayments within 60 days to avoid False Claims Act (FCA) liability. Indest III, J.D.,

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Overpayments Overpayment Medicare Medicare 40

Hall Render

JANUARY 12, 2023

On December 27, 2022, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule that could potentially have a significant impact on enrollees’ obligations under the “60-day” overpayment rule. In fact, claims reviews to quantify an overpayment is a time-consuming effort and the six-month period is necessary.

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Healthcare Law Blog

FEBRUARY 3, 2023

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] New Subpart 521-1: Compliance Programs The adopted regulations represent substantial changes to 18 N.Y.C.R.R.

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Medicaid Medicaid Compliance Overpayments 52

The Health Law Firm

AUGUST 18, 2022

Board Certified by The Florida Bar in Health Law Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are some very real possibilities. Indest III, J.D.,

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Medicaid Medicaid Overpayments Overpayment 52

HIT Consultant

JUNE 15, 2023

Rising Costs of Inaccurate Drug Discount Claims As the Medicaid Drug Rebate Program (MDRP), 340B Drug Pricing Program and other similar programs expand, so do the volume and cost of duplicate discounts and other inaccurate drug discount claims.

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Overpayments Overpayment Medicaid Medicaid 98

Hall Render

FEBRUARY 14, 2023

billion in overpayments from MAOs for payment years 2011 through 2017. billion in overpayments from MAOs for payment years 2011 through 2017. Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs.

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Health Law Advisor

FEBRUARY 2, 2023

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. billion between 2023 and 2032 from MAOs based on both non-extrapolated and extrapolated overpayment amounts.

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Medicare Medicare Overpayments Overpayment 98

The Health Law Firm

JULY 6, 2015

FACTS: Via three Final Audit Reports dated July 10, 2013, AHCA advised the Chrysalis Center that it had overbilled the Medicaid program by $284,535.83 for community mental health services.

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Medicaid Medicaid Overpayments Overpayment 40

The Health Law Firm

JANUARY 30, 2020

We have gotten calls from healthcare professionals, including physicians, dentists, pharmacists, mental health counselors, and assisted living facilities (ALFs) who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results. Once placed on prepayment review, the payments are held up for many months.

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Overpayments Overpayment Medicaid Medicaid 40

The Health Law Firm

JULY 17, 2012

Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are some very real possibilities. By Lance O. Leider, J.D. The unfortunate truth is that Florida has become synonymous with healthcare fraud.

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Medicaid Medicaid Overpayments Overpayment 40

The Health Law Firm

JULY 17, 2015

Florida health care providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are very real possibilities. Facts You Should Know About the Medicaid Audit Process.

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Medicaid Medicaid Overpayments Overpayment 40

The Health Law Firm

JULY 24, 2017

Board Certified by The Florida Bar in Health Law Health care providers in Florida who service Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are very real possibilities. Indest III, J.D.,

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Medicaid Medicaid Overpayments Overpayment 40

The Health Law Firm Blog

JANUARY 12, 2024

Board Certified by The Florida Bar in Health Law The nation's largest Medicaid insurer, Centene, has agreed to pay $165.6 million to Texas to resolve claims that it overcharged the state’s Medicaid program for pharmacy services. By George F. Indest III, J.D., The deal was signed on July 11, 2022, but wasn’t publicly [.]

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

OCTOBER 18, 2022

Board Certified by The Florida Bar in Health Law The nation's largest Medicaid insurer, Centene, has agreed to pay $165.6 million to Texas to resolve claims that it overcharged the state’s Medicaid program for pharmacy services. By George F. Indest III, J.D., The deal was signed on July 11, 2022, but wasn’t publicly [.].

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

NOVEMBER 18, 2023

Board Certified by The Florida Bar in Health Law The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), and Bureau of Medicaid Program Integrity is the Florida agency responsible for routine Medicaid audits The agency ensures that the Medicaid program was billed correctly for [.] Indest III, J.D.,

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

AUGUST 24, 2022

Board Certified by The Florida Bar in Health Law The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), and Bureau of Medicaid Program Integrity is the Florida agency responsible for routine Medicaid audits The agency ensures that the Medicaid program was billed correctly for [.]. Indest III, J.D.,

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

SEPTEMBER 20, 2023

Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

AUGUST 24, 2023

Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

JULY 19, 2023

Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

JUNE 27, 2023

Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]

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Medicaid Medicaid Overpayment Overpayments 52

The Health Law Firm Blog

MAY 16, 2023

Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]

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Medicaid Medicaid Overpayment Overpayments 52

Health Care Law Brief

MAY 11, 2022

No bonus amount may be paid to any worker who has been suspended or excluded under the Medicaid program during the vesting period and at the time an employer submits a claim. Bonus amounts will be commensurate with the number of hours worked by covered workers during designated vesting periods up to a total of $3,000 per covered worker.

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Medicaid Medicaid Overpayments Overpayment 97

Health Law Advisor

AUGUST 25, 2023

It is axiomatic that New York State requires every Medicaid provider to have an “effective” compliance program. Part 521, make several important changes that will affect all Medicaid Providers’ compliance programs throughout New York State. New York Social Services Law § 363-d. The final regulations, codified at 18 N.Y.C.R.R.

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Compliance Overpayments Overpayment Compliance Officers 52

AIHC

MAY 28, 2025

A coding algorithm that misclassifies a procedure or service can lead to overpayments and potential allegations of fraud. link] Centers for Medicare & Medicaid Services (CMS). Financial Accountability and Algorithmic Errors AI tools involved in billing or coding introduce serious financial accountability considerations.

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Compliance Overpayments Overpayment FDA 58

Hall Render

JANUARY 10, 2025

On January 1, 2025, the Centers for Medicare and Medicaid Services’ (“CMS”) new 60-Day Rule became effective. However, under the updated rule, the obligation to report and return an overpayment begins upon identification, even if the exact amount is undetermined. The rule is codified at 42 U.S.C. 1320a-7k(d).

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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. The defendants disagreed.

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Overpayments Overpayment Fraud Governance 52