SCOTUS rejects UnitedHealth appeal of Medicare Advantage overpayment rule

Healthcare Dive

The justices declined to take up the case, leaving intact a lower court ruling that backed the 2014 CMS regulation requiring swift return of overpayments

Payers recover overpayments 50% faster with enterprise technology: study

Fierce Healthcare

Payers recover overpayments 50% faster with enterprise technology: study. jpiatt. Mon, 11/07/2022 - 12:43

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Inspector General pushes CMS to recover $226M in Medicare overpayments

Modern Healthcare

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

Understanding Basics of Medicare Overpayment

Medisys Compliance

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.

Feds sue Cigna over alleged Medicare Advantage overpayments linked to home assessments

Fierce Healthcare

Feds sue Cigna over alleged Medicare Advantage overpayments linked to home assessments. pminemyer. Mon, 10/17/2022 - 15:46

OIG calls on CMS to do more to collect Medicare overpayments from hospitals

Fierce Healthcare

OIG calls on CMS to do more to collect Medicare overpayments from hospitals. rking. Fri, 10/28/2022 - 15:03

Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations.

Centene Reaches $166 Million Settlement With Texas Over Its Medicaid Drug Pricing

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., 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.

Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations.

Lawmakers ‘disheartened’ by CMS’ oversight of Medicare Advantage amid coverage denials, overpayments

Fierce Healthcare

Lawmakers ‘disheartened’ by CMS’ oversight of Medicare Advantage amid coverage denials, overpayments. rking. Tue, 06/28/2022 - 15:48

Supreme Court declines to hear UnitedHealth's lawsuit on Medicare Advantage overpayments rule

Fierce Healthcare

Supreme Court declines to hear UnitedHealth's lawsuit on Medicare Advantage overpayments rule. rking. Wed, 06/22/2022 - 13:03

Centene to pay more than $71M to settle Medicaid overpayment cases in Illinois, Arkansas

Fierce Healthcare

Centene to pay more than $71M to settle Medicaid overpayment cases in Illinois, Arkansas. pminemyer. Thu, 09/30/2021 - 16:43

The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule

Health Care Law Brief

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.

PBM practices are keeping consumers from generics savings, white paper finds

Healthcare Dive

Consumers are overpaying for generic drug prescriptions by as much as 20% due to pharmacy benefit manager practices like copay clawbacks and spread pricing, researchers found

CMS To Relax Medicare 60-Day Overpayment Rule

The Health Law Firm

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. Under the rule, overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received. By George F. Indest III, J.D.,

Doctor Indicted in $1.3 Million Medicare Fraud Kickback Case Seeks Reinstatement of Medicare Billing Privileges

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., 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 million Medicare fraud scheme asked a New Jersey court to eliminate a bail condition. The doctor argued that the.

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Are You the Target of a Medicaid Audit? Tips Health Professionals Should Be Following

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A.,

Florida Surgeon, Device Company Owner Arrested For Paying Bribes, Kickbacks

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law On September 7, 2021, federal prosecutors announced the arrest of a Florida surgeon and owner of device company SpineFrontier Inc on charges of bribing surgeons to use products by paying sham consulting fees. Accused in an indictment in.

Steps to Take If You Receive an OIG Subpoena from the U.S. Department of Health and Human Services

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law The U.S. Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG).

Supreme Court Rules Against HHS in Hospital Medicare Reimbursement Case

The Health Law Firm Blog

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law On June 15, 2022, the U.S. Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals.

Healthcare Professionals: You Must Challenge Overpayment Demands from Medicare and Medicaid Audits

The Health Law Firm

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law. 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. Some providers are even forced out of business as a result.

CMS fix for 340B Supreme Court ruling divides providers

Modern Healthcare

Providers that don't participate in the 340B program say CMS's plan would lead to unfair overpayments to 340B providers

Home health agencies make legal case against CMS' proposed cuts

Modern Healthcare

CMS could consider a policy more like the one it used to correct for overpayments to nursing homes, home health leaders said.

Medicaid Providers Beware: Failure to Appeal Audit Results or Pay Medicaid Overpayments May Result in Termination of License

The Health Law Firm

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. Instead of requesting a formal administrative hearing to contest the overpayment assessment, they had failed to respond or only requested an informal hearing. This resulted in a Medicaid overpayment assessment. By George F. Indest III, J.D.,

A million-dollar healthcare compliance monitoring mistake 

YouCompli

That’s a 41% error rate with an extrapolated overpayment of?$269 Don’t let processes overwhelm clinical colleagues. Helping our clinical colleagues feel the urgency of compliance monitoring can be a huge challenge.

Health Facility Entitled to Attorney's Fees Against AHCA in Defending Medicaid Overpayment Case

The Health Law Firm

By George F. Indest III, J.D., M.P.A., Board Certified by The Florida Bar in Health Law The following is a summary of a recent administrative hearing case on an issue relevant to health law, decided by the Florida Division of Administrative Hearings (DOAH). 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.

Becerra eyes work on physician pay, Medicare Advantage reform

Modern Healthcare

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

Healthcare Professionals: Do You Know How to Prepare For, and Respond To, a Medicaid Audit Request?

The Health Law Firm

As a result, auditing and subsequent overpayment demands are some very real possibilities. By George F. Indest III, J.D., M.P.A.,

What If Costco Designed the Prescription Drugs Sales Model?

Health Populi

Consumers Overpay for Generic Drugs , a new paper from the Leonard Schaeffer Center for Health Policy & Economics asserts, with recommendations to address the intermediaries who benefit from the way Americans currently pay for medicines.

AI Provider Anomaly Launches Tech to Predict Claims Denials with 97% Accuracy

HIT Consultant

What You Should Know: – Anomaly , a precision payments company streamlining healthcare billing and payments for providers and payers, today announced its new offering Anomaly Smart Response.

Avoiding Red Flags: Finding the Right Productivity Balance

Healthcare IT Today

The payer could also recoup the overpayments from future visits. . The following is a guest article by John Wallace, PT, OCS, Senior Vice President of RCM at WebPT. When it comes to the number of patients providers can see in a day, some might think that more is more.

OIG Posts False Claims Act Settlements for FY 2022 Q1–Q4 on the Risk Spectrum

Healthcare Compliance Blog

If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability.

Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging

Kaiser Health News

They also called for the Centers for Medicare & Medicaid Services, or CMS, to revive a foundering audit program that is more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.

California pharmacies will no longer be required to pay back the state under its new reimbursement methodology

Natalia Mazina

This lead to overpayments to pharmacies. 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.

Georgia Nursing Home Settles to Resolve Allegations of False Claims for Therapy Services

Healthcare Compliance Blog

an overpayment), make all reasonable efforts to determine if inappropriate billing occurred, if any related overpayments exist, and if found, return the funds to Medicare within 60 days of identification. .

Medicaid: New Guidance from CMS Finds there are Significant Misunderstandings on Ground Emergency Medical Transportation Cost-Based Reimbursements

Healthcare Law Today

” As CMS notes, “[c]osts that are claimed improperly may be subject to financial reviews and/or audit findings and place states at financial risk of liability to repay the federal share of any identified overpayments.”

OIG Revises Self-Disclosure Protocol

Florida Health Care Law Firm

The OIG clarified that using the SDP may mitigate potential exposure under Medicare and Medicaid 60-day reporting and returning requirements for overpayments. Any overpayment retained after this period may create liability under the Civil Monetary Penalties Law and the False Claims Act. The Centers for Medicare & Medicaid Services (CMS) agreed to suspend the obligation to report overpayments under the Act when the OIG acknowledges receipt of a timely submission to the SDP.

Kmart Agrees to Pay $32.3 million to Settle Whistle Blower’s False Claims Act Suit

The Health Law Firm

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

What You Need to Know About Preparing and Responding to an Initial Medicaid Audit Request

The Health Law Firm

As a result, auditing and subsequent overpayment demands are very real possibilities. By George F. Indest III, J.D., M.P.A., 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. The unfortunate truth is that Florida has become synonymous with health care fraud.

These are the compliance issues providers should be preparing for, post-PHE

Healthcare IT News - Telehealth

Additionally, any reimbursement resulting from these claims could be considered an overpayment. Once a provider has credible evidence of an overpayment, it must be reported and returned to avoid triggering FCA liability.

Posthospital SNF Care in Indiana Generally Met Medicare Level-of-Care Requirements

Healthcare Compliance Blog

an overpayment), make all reasonable efforts to determine if the skilled level of care is appropriate before submitting a claim to Medicare. If inappropriate billing occurred and any related overpayments exist, return the funds to Medicare within 60 days of identification. .

Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough

McBrayer Law Blog

The estimated overpayment as a result of these coding errors is a reported $1 billion.

KHN’s ‘What the Health?’: Finally Fixing the ‘Family Glitch’

Kaiser Health News

For the first time, Medicare Advantage plans are poised to enroll more than half of the Medicare population despite allegations that many of the largest insurers are getting billions of dollars in overpayments from the federal government. Can’t see the audio player?

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