Health Populi

JUNE 5, 2022

The good news about prescription drugs, in the context of medical spending in the U.S., But there’s bad news about prescription drugs in the context of medical spending in America. Today, the three largest PBMs, processing about 4 in 5 retail prescription claims, are embedded in large health insurance companies.

Overpayments 149

Overpayments Overpayment Medicare Medicare 149

Health Care Law Brief

APRIL 12, 2023

With respect to digital health literacy, MA plans will be obligated to offer to beneficiaries education about digital health so that they may access benefits furnished through telehealth when their provider is at a different location. See 42 U.S.C. 1320a-7k(d)(2) (“60 Day Rule”). See Proposed Rule at 79559. See 42 C.F.R. 401.305(a)(2).

Medicare 52

Medicare Medicare Overpayments Overpayment 52

HIT Consultant

MARCH 20, 2024

The HHS Office of Inspector General (OIG) recently reported that, from October 2014 through December 2016 , 153 audit reports were issued containing 193 overpayment recoveries totaling $648 million, largely due to errors in medical documentation. million (net) and $4.7 billion from 2023 through 2032, including extrapolation effects.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

Healthcare IT News - Telehealth

JUNE 8, 2022

based attorney in the health law practice of Baker, Donelson, Bearman, Caldwell & Berkowitz about what providers should be doing to ensure compliance when the PHE finally sunsets. Additionally, any reimbursement resulting from these claims could be considered an overpayment. We spoke recently with Allison M.

US Department of Health and Human Services 180

US Department of Health and Human Services Compliance Overpayments Overpayment 180

The Health Law Firm

JULY 24, 2017

As a result, auditing and subsequent overpayment demands are very real possibilities. Indest III, J.D., 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.

Medicaid 40

Medicaid Medicaid Overpayments Overpayment 40

HIT Consultant

JANUARY 9, 2024

They can reduce the burden on clinical and financial staff for payments, disputes, reporting and reconciliations, all while minimizing site and study overall costs and overpayments. About Jim DiCesare Jim DiCesare is passionate about delivering innovative site activation and site payment services to clinical trials.

Overpayments 95

Overpayments Overpayment COVID-19 Fraud 95

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.

Compliance 107

Compliance Overpayments Overpayment Medicare 107

Healthcare IT Today

NOVEMBER 22, 2022

The payer could also recoup the overpayments from future visits. . About John Wallace. Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. In a best-case scenario, they can deny payment or ask to be repaid for the visits they found were overbilled during the audit.

Medicare 95

Medicare Medicare Overpayments Overpayment 95

Health Care Law Brief

APRIL 3, 2023

We summarize the key factors and adjustments to the overall expected average rate increase of 3.32% (which is about $13.8 In the Advance Notice, CMS predicted that the changes to the risk scores and HCC updates will help prevent overpayments by improving the accuracy of payments made to MAOs. See 88 Fed. 6643 (Feb.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

YouCompli

FEBRUARY 22, 2023

In fact, the Office of the Inspector General (OIG) has had multiple items about outlier payments on its work plan and has conducted audits in this area. They found the facility correctly billed 17 of the 120 but incorrectly billed the remaining 103 claims, which totaled over $580,000 in overpayments. Be sure to meet that timeline.

Compliance 52

Compliance US Department of Health and Human Services Overpayments Overpayment 52

Healthcare IT Today

FEBRUARY 2, 2024

This reactive model leads to only ~70% of identified overpayments being recovered and/or corrected. With deeply entrenched legacy systems, many payers are anxious about their return on investment, which might cause them to resist adopting advanced pre-payment technologies. Providers navigate abrasive recoveries and revenue instability.

Payment Systems 66

Payment Systems Overpayments Overpayment Medical Billing 66

Compliancy Group

FEBRUARY 2, 2024

The DOJ will also determine if there is sufficient communication to employees informing them about the compliance program and garnering commitment to its mission. Tangible indicators of sufficient resources and effort include adequate staff assigned to conduct audits and document and analyze the results of the program’s efforts.

Compliance 52

Compliance Overpayments Overpayment Compliance Officers 52

Healthcare IT Today

FEBRUARY 22, 2023

” I talked recently to Meleah Bridgeford, senior director of risk adjustment analytics at Episource , about how their analytics and billing solution can improve the quality of submissions and payments at Medicare Advantage plans. CMS requires chart reviews to catch overpayments. They’re valuable for many reasons.

Medicare 88

Medicare Medicare Overpayments Overpayment 88

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. Indest III, J.D., Board Certified by The Florida Bar in Health Law On December 22, 2017, Kmart Corporation agreed to pay $32.3

Overpayments 40

Overpayments Overpayment Medicaid Medicaid 40

YouCompli

MAY 17, 2023

Related: Jay Anstine on playing productive politics (and avoiding destructive politics) So, what do we do about that? Use topics like physician contracting to facilitate discussion about your charter. Using that time to brief Legal about key Compliance issues and proposed corrective action plans has always been beneficial.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

Compliancy Group

FEBRUARY 7, 2024

You may have been hearing about UPIC (Unified Program Integrity Contractor) audits more often lately. The outcome of these audits can range from repayment of overpayments to criminal prosecution in cases of fraud. Who Should Be Concerned About CMS UPIC Audits?

Fraud 52

Fraud Compliance Medicare Medicare 52

Hall Render

AUGUST 4, 2023

CMS described the increase as a “parity adjustment recalibration,” noting that it had previously overestimated overpayments to nursing homes, which resulted in an unintended reduction in reimbursement in 2023. Currently, the health system pays about $1.1

Hospitals 40

Hospitals Overpayments Overpayment Nursing Homes 40

The Health Law Firm

JULY 17, 2015

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

Medicaid 40

Medicaid Medicaid Overpayments Overpayment 40

YouCompli

NOVEMBER 1, 2023

That person holds an entrance conference with the department director, and reviews the documentation against the regulatory requirements, but never communicates with the director about how they provide and document the service for billing purposes. Such a situation would raise concerns about that auditor’s ability to do their work properly.

Compliance 52

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

Hall Render

DECEMBER 27, 2023

Specific detail about the exceptions is outlined below. Further, entities should review non-monetary compensation provided in 2023 to ensure that such compensation did not exceed the 2023 limit of $489 and take any necessary corrective action to repay excess amounts within 180 days of the overpayment or by December 31, 2023.

Hospitals 75

Hospitals Overpayments Overpayment Medicaid 75

YouCompli

FEBRUARY 1, 2023

It’s also about enabling patients to report their concerns anonymously. It’s about compliance officers fostering a culture of compliance. Developing effective lines of communication The fourth element involves making sure patients are comfortable asking about the organization’s policies and practices.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

YouCompli

SEPTEMBER 13, 2023

This three-pronged strategy focuses on educating patients and staff about how to avoid misconduct. Step 1: Prevent To educate patients about FWA, compliance professionals can create materials for waiting rooms that give simple examples of what FWA looks like. Here’s where the “prevent, detect, report” concept comes into play.

US Department of Health and Human Services 52

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

Med-Net Compliance

OCTOBER 21, 2022

Because the OIG’s assessment of the risk posed by a FCA defendant may be relevant to various stakeholders, including patients, family members, and healthcare sector professionals, the information about where a FCA defendant falls on the risk spectrum is made public.

Fraud 59

Fraud Compliance Medicare Medicare 59

YouCompli

OCTOBER 26, 2022

That’s a 41% error rate with an extrapolated overpayment of?$269 Yes, you and these other departments can assist if there are questions about interpreting a regulation. This insight can help you determine how diligent your colleagues are about monitoring. 269 million.?. However, Clinical Leaders must take responsibility for.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

Healthcare IT Today

FEBRUARY 2, 2023

One last note about conducting quality assurance audits: Remember to close the loop. At $1,000 per code, these errors pointed to a possible overpayment of $64,000 for the identified members. Provider Education: This helps identify missed or incorrect (or both) usage of ICD-10 codes from locations where education was provided (i.e.,

Medicare 59

Medicare Medicare Medicaid Medicaid 59

Healthcare Law Blog

FEBRUARY 9, 2024

Sherman himself had submitted disclosure logs to the OIG), Sherman alleges that it failed to adequately report the arrangements it had with Neonatology Associates or any other private physician groups, or return any alleged overpayments. FOOTNOTES [1] Other Defendants include ChristianaCare Health Services, Inc.,

Hospitals 52

Hospitals Compliance Officers Compliance Overpayments 52

Innovaare Compliance

MARCH 24, 2024

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. Some providers argued that the AI system’s decisions were opaque and lacked clear explanations, making it difficult for them to understand and challenge claim denials.

Fraud 52

Fraud Health Insurance Compliance Medicaid 52

Health Law RX

JANUARY 30, 2024

Although the DOJ was silent about application of the M&A Safe Harbor to civil enforcement under the FCA, other DOJ guidance emphasizes the DOJ’s willingness to provide benefits to entities and individuals who voluntarily self-disclose in the FCA context. The GCPG further explains how to implement these elements. Ensure Ongoing Compliance.

Compliance 52

Compliance Due Diligence Fraud Governance 52

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

Healthcare IT Today

MAY 5, 2023

By taking a proactive, data-driven approach to genetic testing fraud, waste and abuse, health plans can protect members from unnecessary testing, prevent inappropriate claims from being paid, and improve their chances of recovery when an overpayment occurs.

Fraud 62

Fraud Medicare Medicare Overpayments 62

Hall Render

APRIL 19, 2024

Can lawmakers do anything about it? to Study Treatments for Vascular Abnormalities Federal Appeals Court Hears Arguments on Nation’s First Ban on Gender-affirming Care for Minors Jason Demke Hired as COO at Mercy Hospital Fort Smit Pulaski Tech Awarded $5.7M health system seeking $150M from state to jumpstart hospital project Pr.

Nursing Homes 40

Nursing Homes Nurses Hospitals Doctors 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. Substance use disorders impact a significant number of individuals, families, and communities.

COVID-19 59

COVID-19 Telemedicine Compliance Informed Consent 59

Hall Render

DECEMBER 6, 2022

Specific detail about the exception is outlined below. Further, entities should review non-monetary compensation provided in 2022 to ensure that such compensation did not exceed the 2022 limit of $452 and take any necessary corrective action to recover excess amounts within the earlier of 180 days of the overpayment or by December 31, 2022.

COVID-19 40

COVID-19 Hospitals Overpayments Overpayment 40

YouCompli

DECEMBER 14, 2022

Here, any overpayment from a governmental payer source must be returned within 60 days of its identification. Never miss an article about compliance officer effectiveness – register to receive emails from YouCompli. Those issues can help with early identification of localized and more systemic issues.

Compliance 52

Compliance Compliance Officers Nurses Overpayments 52

AIHC

APRIL 5, 2022

If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back. More information about OIG's self-disclosure protocol – click here. When you believe the payer is making the mistake, push back by exhausting all appeal rights allowed.

Fraud 52

Fraud Compliance Medicare Medicare 52

Redox

APRIL 29, 2019

This two-part blog aims to start a conversation about what inhibits change and how to make it happen better. I wrote a few years ago about how health IT is in its awkward teenage years but now it’s more like a child star going through puberty in the public eye. Physician “Burnout” / Moral Injury.

Doctors 40

Doctors Overpayments Overpayment Health Insurance 40

CMS.gov

NOVEMBER 16, 2018

These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred. To view CMS’s fact sheet with more information about Improper Payment Reductions, please visit: [link]. ###.

Medicare 20

Medicare Medicare Overpayments Overpayment 20