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”). One thing that is certain, CMS can expect further challenges to its RADV audit methodology. 3d 1, 18 n.19

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Medicare Medicare Overpayments Overpayment 105

YouCompli

MARCH 22, 2023

There has been significant enforcement over the last couple years relating to overpayments for UDT. According to the OIG, prior error rate testing has suggested an improper payment rate of almost 30% for Medicare. The overpayment rate for definitive drug testing for 22 or more drug classes was over 71%.

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Overpayments Overpayment Compliance Medicare 52

Healthcare IT Today

FEBRUARY 22, 2023

There’s widespread consensus that payments to Medicare Advantage Organizations (MAOs) are a mess. These programs, which care for more than 30 million of the nearly 64 million Medicare enrollees , operate on the cutting edge of health care and suffer serious problems in data collection and billing.

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Medicare Medicare Doctors Overpayments 115

Modern Healthcare

JULY 28, 2022

An OIG audit outlined millions in uncollected overpayments, holes in internal accounting system

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Overpayments Overpayment Medicare Medicare 116

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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Overpayments Overpayment Medicare Medicare 40

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. The final rule codifies long-awaited regulations first proposed by CMS in 2018. This total includes $41.1

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Medicare Medicare Overpayments Overpayment 98

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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Overpayments Overpayment Medicare Medicare 52

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. Medicare Advantage plans accept a set fee from the government for covering a person’s health care.

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Medicare Medicare Governance Overpayments 122

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. Congress also required CMS to use the “same methodology” to calculate the costliness of insuring a beneficiary in the MA program and in FFS Medicare.

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Overpayments Overpayment Medicare Medicare 52

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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Overpayments Overpayment Medicare Medicare 40

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. The SRFs include low-income subsidy, dual eligibility (meaning eligible for Medicare and Medicaid) and disability.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Modern Healthcare

MARCH 17, 2022

As Xavier Becerra approaches his one-year anniversary at HHS' helm, he's interested in working with Congress on Medicare Advantage overpayment issues and physician payment reform.

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Medicare Medicare Overpayments Overpayment 88

Health Care Law Brief

APRIL 3, 2023

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ( Rate Announcement ). 1395w-23): Medicare Advantage Organizations (MAOs) are paid a base rate by CMS. ., Risk Adjustment.

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Medicare Medicare Overpayments Overpayment 52

Healthcare Compliance Blog

APRIL 14, 2022

The Office of Inspector General (OIG) released their findings of an audit they conducted to determine if hospital admissions of Indiana skilled nursing facility (SNF) residents who are enrolled in both Medicare and Medicaid (dually eligible beneficiaries) were potentially avoidable, and if level-of-care requirements for Medicare were met.

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Medicare Medicare Nurses Medicaid 59

The Health Law Firm Blog

MAY 17, 2023

Board Certified by The Florida Bar in Health Law Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. By George F. Indest III, J.D.,

Medicare 52

Medicare Medicare Nurses Overpayments 52

Healthicity

NOVEMBER 29, 2022

Health and Human Services Office of Inspector General (OIG) recently issued a report concluding that Medicare and patients combined overpaid more than a million dollars for the same professional services provided at critical access hospitals (CAH). Who Bills for Professional Services?

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Overpayments Overpayment Hospitals Medicare 52

Health Populi

JUNE 5, 2022

In 2006 the Medicare Part D program was implemented, covering older Americans for prescription drugs for the first time. Medicare further drove expansion of generic drug utilization, with co-pays for generics lower for Medicare enrollees than branded drugs. ., is that 9 in 10 medicines prescribed are generics.

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Medicare Medicare Health Insurance Overpayments 154

Healthcare IT Today

FEBRUARY 25, 2023

Read more… Retrieving Billions in Medicare Overpayments. Improper payments for Medicare are estimated to exceed $43 billion per year, and determining overpayments in open-ended value-based Medicare Advantage plans poses a problem. Read more… Fixing Medicare Advantage Payments.

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Overpayments Overpayment Medicare Medicare 119

Innovaare Compliance

MARCH 1, 2022

The monthly premium for Medicare Part B rose 14.5%, from $148.50 By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1] By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1]

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Medicare Medicare Overpayments Overpayment 52

NEJM

JANUARY 13, 2023

A 2022 Supreme Court ruling raises questions about the 340B program’s outsized effect on the health care system’s structure and on the role of hospitals in providing care to underserved populations.

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Overpayments Overpayment Medicare Medicare 51

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.

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Overpayments Overpayment Medicare Medicare 40

Healthcare IT Today

NOVEMBER 22, 2022

The number of Medicare TPEs and commercial payer take-back audits alone is skyrocketing. They also look to flag “items and services that have high national error rates and are a financial risk to Medicare.” Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. Tricare and Medicare).

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Medicare Medicare Overpayments Overpayment 111

The Health Law Firm Blog

MARCH 16, 2022

million Medicare fraud scheme asked a New Jersey court to eliminate a bail condition. Indest III, J.D., Board Certified by The Florida Bar in Health Law On November 2, 2021, a doctor and his wife who had been indicted for their roles in a $1.3 The doctor argued that the.

Medicare 52

Medicare Medicare Doctors Fraud 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. 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 [.].

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Medicare Medicare Hospitals Governance 52

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”). Health Equity in Medicare Advantage. We’ve summarized some of the key changes in the Proposed Rule.

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Medicare Medicare Medicaid Medicaid 52

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 Medicaid Medicaid 52

Healthcare IT News - Telehealth

JUNE 8, 2022

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. If Medicare coverage requirements for telehealth services (e.g., More practitioners can provider covered telehealth services (e.g.,

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US Department of Health and Human Services Compliance Medicare Medicare 196

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.

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Fraud Medicare Medicare Overpayments 72

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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Medicaid Medicaid Medicare Medicare 40

Kaiser Health News

OCTOBER 13, 2022

Meanwhile, open enrollment for Medicare begins Oct. 15, when beneficiaries can join or change private Medicare Advantage plans or stand-alone prescription drug plans. Many seniors are happy with their Medicare Advantage plans, which often offer more benefits than traditional Medicare at a reduced cost.

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Medicare Medicare ACA Overpayments 96

YouCompli

FEBRUARY 22, 2023

Most federal healthcare payors such as Medicare and Medicaid reimburse most providers on a prospective basis. This is why Medicare publishes its rules on their Inpatient Prospective Payment System (IPPS) or its Outpatient Prospective Payment System (OPPS). The inflated charges resulted in inappropriate outlier payments from Medicare.

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Compliance US Department of Health and Human Services Medicare Medicare 52

HIT Consultant

AUGUST 22, 2022

Smart Response complements Anomaly’s planned suite of products powered by its AI claim prediction engine, including overpayment prediction, which enables payers to predict and prevent overpayments by learning from previously overpaid claims, and instant payments, which will enable providers to immediately get paid upon claim submission.

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Overpayments Overpayment Medicaid Medicaid 52

Healthcare Compliance Blog

MARCH 16, 2022

In a March 11, 2022, release by the Northern District of Georgia’s Office of the Department of Justice, it was reported that an investigation determined a Georgia nursing home knowingly submitted claims for unreasonable, unnecessary, and unskilled services for Medicare patients. This amount was based on the nursing home’s ability to pay.

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Nursing Homes Nurses Overpayments Overpayment 59

Healthcare IT Today

FEBRUARY 2, 2023

As proof, several health plans have been making headlines for coding errors and other issues that surfaced during audits: In just the third quarter of 2022, at least four audits have specifically targeted Medicare Advantage plans. The New York Times claimed eight of the 10 largest Medicare Advantage insurers had padded their bills.

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Medicare Medicare Medicaid Medicaid 69

McBrayer Law Blog

NOVEMBER 18, 2020

The estimated overpayment as a result of these coding errors is a reported $1 billion. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims.

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Compliance Medicare Medicare Medicaid 52

Healthcare Compliance Blog

JUNE 9, 2022

Between 2017 and 2019, the man, through a group of pain clinics he controlled, caused the submission of false claims for payment to Medicare. HHS-OIG will continue to work with the US Attorney’s Office to ensure the integrity of the Medicare Trust Fund.”. He is awaiting sentencing on those charges.

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US Department of Health and Human Services Medicare Medicare Medicaid 59

Healthcare Law Blog

MARCH 2, 2023

Effective March 1 st , certain providers choosing to self-disclose Stark Law violations must use forms updated by the Centers for Medicare & Medicaid Services (“CMS”). Once CMS acknowledges receipt of a provider’s SRDP submission, the provider’s obligation to report and return overpayments within 60 days is suspended. See 42 C.F.R.

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Medicare Medicare Medicaid Medicaid 52