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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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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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. The final rule codifies long-awaited regulations first proposed by CMS in 2018.

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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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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.

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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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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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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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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. Attorney Kurt R. Update as needed.

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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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Healthcare Law Blog

SEPTEMBER 28, 2023

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. MAOs will be required to remit improper payments identified during RADV audits in a manner specified by CMS.

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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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The Health Law Firm Blog

JANUARY 8, 2024

Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG). This agency investigates allegations of fraud, waste, and abuse of Medicare, Medicaid, and other federally funded healthcare programs. [.] Indest III, J.D.,

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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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The Health Law Firm Blog

JUNE 10, 2023

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 [.]

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Healthcare IT Today

NOVEMBER 22, 2022

After all, more patients should generate more billable services—and thus, more payments. The number of Medicare TPEs and commercial payer take-back audits alone is skyrocketing. Medicare’s Targeted Probe and Educate audits use data analysis to identify clinics who have high claim error rates or unusual billing practices.

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Healthcare IT News - Telehealth

JUNE 8, 2022

The Department of Health and Human Services once again (for the ninth time) extended the public health emergency this past month , stretching it beyond mid-July. But sooner or later, that provision of the Public Health Service Act will draw to a close. More practitioners can provider covered telehealth services (e.g.,

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Provider Trust

JUNE 30, 2023

Payers within the healthcare ecosystem understand the complexities and importance of maintaining integrity when submitting or evaluating payments for medical services rendered by providers. This means payers must rely on post-payment reviews and audits to identify those errors, overpayments, and fraudulent claims.

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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.

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The Health Law Firm Blog

OCTOBER 14, 2022

Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG). This agency investigates allegations of fraud, waste, and abuse of Medicare, Medicaid, and other federally funded healthcare programs. [.]. Indest III, J.D.,

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Compliancy Group

FEBRUARY 7, 2024

This is because the Centers for Medicare & Medicaid Services (CMS) have ramped up their efforts to identify organizations that have improperly billed for medical services. The Centers for Medicare and Medicaid Services (CMS) created UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid.

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Healthicity

APRIL 12, 2022

The OIG’s Annual Workplan for 2022 includes the continuous auditing and monitoring of items and services.

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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 To address these concerns and other matters, CMS announced significant regulatory changes to the Medicare Advantage (MA) program beginning in 2024. million (net) and $4.7

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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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Healthcare IT Today

JANUARY 17, 2024

External Audits Surge Among the report’s standout findings is the significant uptick in external payor audits in 2023, a result of escalating federal government efforts to address the overpayments made in the past two to three years. Moreover, extended adjudication times (29-35 days) for initial responses to claims impacted cash flows.

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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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Compliancy Group

FEBRUARY 29, 2024

Office of Inspector General (OIG) can invoke civil or criminal prosecution or licensure or other penalties, fines, exclusions from federal programs like Medicare, or revocation of billing privileges. Department of Health and Human Services (HHS) OIG and the organization.

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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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Healthcare Compliance Blog

JUNE 9, 2022

His exclusion means that no federal healthcare program payment may be made, either directly or indirectly, for any items or services furnished by him or at his direction or prescription. Between 2017 and 2019, the man, through a group of pain clinics he controlled, caused the submission of false claims for payment to Medicare.

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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. In addition, CMS education and outreach focuses on preventing, detecting, and reporting Medicare fraud and abuse.

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Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 They also raised concerns about the fairness and accuracy of the AI algorithms, suggesting that the system might be biased against certain types of providers or services. The Challenge of Health Care Fraud.

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CMS.gov

NOVEMBER 16, 2018

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Administrator, Centers for Medicare & Medicaid Services. 2018 Medicare Fee-For-Service improper payment rate is lowest since 2010 Significant progress in saving $4.59B in estimated improper payments for the Medicare Fee-For-Service program.

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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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Natalia Mazina

JULY 3, 2022

Back in 2017, the California Department of Healthcare Services (DHCS) approved a new methodology – National Average Drug Acquisition Cost (NADAC) – for reimbursing pharmacies for their drug cost. This lead to overpayments to pharmacies. NADAC prices significantly reduced pharmacy reimbursements. See a related blog post.

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The Health Law Firm

OCTOBER 9, 2013

Board Certified by The Florida Bar in Health Law The University of Miami Hospital allegedly owes Medicare $3.7 The report was released on October 8, 2013, by the US Department of Health and Human Services (HHS) Office of Inspector General (OIG). Indest III, J.D.,

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Hall Render

DECEMBER 27, 2023

The dollar limit for “medical staff incidental benefits” provided by a hospital to a member of its medical staff ( e.g. , meals, parking and other items or incidental services that are used on a hospital’s campus) is less than $44 per occurrence. and the entity may not bill for such services unless an exception is met.

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