Healthicity

FEBRUARY 8, 2022

New York Hospital to Pay $389,000 to Medicare. In a recent audit of a New York hospital, the HHS OIG identified overpayments.

Overpayments 98

Overpayments Overpayment Medicare Medicare 98

Healthcare Law Blog

DECEMBER 27, 2022

The Centers for Medicare and Medicaid Services (“CMS”) has issued a proposed rule which would amend the existing regulations for reporting and returning identified overpayments (the “Proposed Rule”). UnitedHealthcare challenged the current Overpayment Rule in litigation. [1] UnitedHealthcare Litigation. The Proposed Rule.

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Overpayments Overpayment Medicare Medicare 98

Fierce Healthcare

JUNE 13, 2023

Legislators and policymakers have put payments to Medicare Advantage (MA) plans under the microscope, and new analysis highlights why. Legislators and policymakers have put payments to Medicare Advantage plans under the microscope, and new analysis highlights why.

Overpayments 122

Overpayments Overpayment Medicare Medicare 122

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. The increased oversight of MA is not surprising given the program’s size and evolving federal priorities.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

HIPAA Journal

JUNE 30, 2025

The Federal Bureau of Investigation (FBI), its Internet Crime Complaint Center (IC3), and the HHS Centers for Medicare & Medicaid Services (CMS) have issued warnings to the healthcare and public health (HPH) sector about ongoing fraud schemes.

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Fraud Overpayments Overpayment Medicare 73

MRO Compliance

JANUARY 16, 2025

To address these gaps, the Centers for Medicare & Medicaid Services (CMS) now mandates the use of FHIR-based APIs for data sharing. Many claims analysts feel that chasing down overpayments feels like plugging leaks in a sinking boat. This is why payers are now shifting toward pre-pay accuracy.

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Overpayments Overpayment Regulatory Compliance Patient Satisfaction 130

Modern Healthcare - Policy

MAY 21, 2025

The Centers for Medicare and Medicaid Services will audit every Medicare Advantage plan, every year to root out improper spending.

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Overpayments Overpayment Medicare Medicare 96

Fierce Healthcare

OCTOBER 6, 2023

million in overpayments from Medicare Advantage in 2015 and 2016. | million in overpayments from Medicare Advantage in 2015 and 2016. A new federal audit estimates that Aetna may have received at least $25.5 A new federal audit estimates that Aetna may have received at least $25.5

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Overpayments Overpayment Medicare Medicare 96

Fierce Healthcare

JULY 14, 2023

Steve Lieberman and other experts co-authored | While insurers would likely fight massive changes to the program, experts say less drastic updates could still go a long way toward lowering overpayments. When Paul Ginsburg, Ph.D.,

Overpayments 98

Overpayments Overpayment Medicare Medicare 98

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

Modern Healthcare - Policy

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 108

Medisys Compliance

JULY 5, 2022

What is Medicare Overpayment? An overpayment is a payment made to a provider exceeding amounts due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require CMS recover overpayments. Medicare Overpayment Collection Process.

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Overpayments Overpayment Medicare Medicare 52

Healthicity

MARCH 6, 2025

The 60-day rule under the Affordable Care Act is one of the most important compliance regulations for healthcare providers accepting Medicare or Medicaid payments. It requires organizations to identify, report, and return any overpayments within 60 days of discovery.

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Overpayments Overpayment Medicaid Medicaid 59

Healthcare Dive

SEPTEMBER 6, 2023

Favorable selection of healthier beneficiaries led to overpayments in counties with high Medicare Advantage penetration, but benchmark changes could mitigate the impact, according to a study published in Health Affairs.

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Overpayments Overpayment Medicare Medicare 152

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 113

Innovaare Compliance

DECEMBER 14, 2023

In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage plans, particularly in the areas of compliance and risk assessment. CMS’s Role and the RADV Audits Program Medicare Advantage overpayments have become alarmingly problematic in the private payer program.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

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

Medicare 98

Medicare Medicare Overpayments Overpayment 98

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. healthcare spending.

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Overpayments Overpayment Medicare Medicare 154

Fierce Healthcare

JANUARY 2, 2024

Medicare Part D will cover certain over-the-counter products when prescribed by a clinician, and when it does, the program pays far more for these drugs, according to a

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Overpayments Overpayment Medicare Medicare 69

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.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

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

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

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 ACA Medicare 52

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

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

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.

Nurses 52

Nurses Compliance Medicare Medicare 52

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.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

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

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 Ransomware Medicare 88

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 107

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.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

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.

Overpayments 58

Overpayments Overpayment Medicare Medicare 58

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.

Medicare 59

Medicare Medicare Overpayments Overpayment 59

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 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

Physician Credentialing Company

MAY 22, 2025

Readers learn about the concept of MSP (Medicare Secondary Payer) in healthcare with an emphasis on its effects on billing, coordination of benefits, and submissions. MSP refers to the term Medicare Secondary Payer. Medicare, on the other hand, pays after another insurer has satisfied his duty.

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Medicare Medicare Medical Billing Overpayments 52

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