AIHC

JANUARY 28, 2022

For more information on filing compliance cost reports, attend the Medicare Cost Report Camp in March 2022 presented by KraftCPAs and sponsored by the American Institute of Healthcare Compliance. This is calculated based on the hospital’s relative share of uncompensated care nationally.

Medicare 52

Medicare Medicare Hospitals Payment Systems 52

Med-Net Compliance

JULY 20, 2022

A federal jury convicted a New York ENT doctor for defrauding Medicare and Medicaid by causing the submission of false and fraudulent claims for surgical procedures that were not performed. Specifically, between January 2014 and February 2018, the doctor billed Medicare and Medicaid approximately $585,000 and was paid approximately $191,000.

Fraud 59

Fraud Doctors Medicare Medicare 59

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

CMS.gov

NOVEMBER 16, 2018

2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Fri, 11/16/2018 - 18:46. Administrator, Centers for Medicare & Medicaid Services. Most notably: The 2018 Medicare-FFS improper payment rate decreased from 9.51 percent in 2018. percent in 2018. percent in 2018.

Medicare 20

Medicare Medicare Overpayments Overpayment 20

Med-Net Compliance

JUNE 15, 2022

California Attorney General Rob Bonta announced a settlement against a Southern California doctor for submitting false claims to Medicare and Medi-Cal between the years of 2011 and 2018 for drugs, procedures, services, and tests that were never administered to patients. two whistleblowers were the doctor’s former?medical

Fraud 59

Fraud Doctors Elder Abuse Medicare 59

Healthcare Compliance Blog

JANUARY 14, 2022

million to settle allegations that the company sold custom fabricated shoe inserts to Medicare recipients that did not meet Medicare standards. Custom shoe inserts for diabetic patients can be covered by Medicare and Medicaid. A Florida based diabetic shoe company has agreed to pay over $5.5

Medicare 59

Medicare Medicare Medicaid Medicaid 59

Natalia Mazina

FEBRUARY 22, 2024

DIR fees were implemented with the creation of the Part D program through the passage of the Medicare Modernization Act of 2003. Other criteria utilized by PBMs include medication adherence rates, generic compliance ratios, generic effective rate, and medication therapy management implementation.

Medicare 137

Medicare Medicare Patient Advocacy Medicaid 137

HIT Consultant

NOVEMBER 22, 2021

July 1, 2021 was the enforcement date for the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access final rule. Compliance Challenges. In this light, the most significant cost of delayed compliance is a lost strategic growth opportunity. John Kelly, Principal Business Advisor, Edifecs.

Compliance 52

Compliance Medicaid Medicaid Medicare 52

Healthcare IT Today

AUGUST 14, 2024

It ensures timely patient access to care, automatic claim processing, network management, compliance, fraud detection, physician recruitment and more. The Centers for Medicare and Medicaid Services reported more than 45% of provider office locations listed in online directories contained at least one error.

Fraud 75

Fraud Hospitals Medicaid Medicaid 75

Hall Render

FEBRUARY 14, 2023

Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs. Extrapolation For audits for payment year 2018 forward, CMS will implement extrapolation of audit findings against the MAOs plan’s entire audit population to derive the overpayment amount.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

Innovaare Compliance

JUNE 21, 2023

The Inflation Reduction Act of 2022 has wide-ranging impact on payments for drugs used by Medicare beneficiaries, whether they are administered in the provider’s office (Part B) or used in the ambulatory setting (Part D). Part B drugs have had the fastest spending growth for drugs for Medicare. percent annually.

US Department of Health and Human Services 52

US Department of Health and Human Services Medicare Medicare Medicaid 52

Innovaare Compliance

MARCH 4, 2024

Until the enactment of the Medicare Modernization Act (MMA) in 2006 [1] , the Centers for Medicare & Medicaid Services does not cover most outpatient prescription drugs under Part B (“Part B drugs”). However, some drugs self-administered by Medicare beneficiaries at home are Part B eligible.

Medicare 52

Medicare Medicare Nurses Medicaid 52

Provider Trust

JULY 26, 2023

The Centers for Medicare and Medicaid Services (CMS) conducted multiple reviews of Medicaid Advantage provider directories between February 2016 and July 2018. Their report from the third round of reviews found that of the 108 providers selected from 52 Medicare Advantage Organizations (MAO) directories, 48.7%

Medicaid 52

Medicaid Medicaid Compliance Medicare 52

Healthcare Law Blog

NOVEMBER 2, 2023

According to the Congressional Research Service, which analyzed data from the Centers for Medicare & Medicaid Services (“CMS”) National Health Expenditure Accounts (“NHEA”) on the personal health expenditures for LTSS by payer, in 2021, an estimated $467.4 As individuals continue to live longer beyond retirement and the U.S.

Nursing Homes 52

Nursing Homes Medicaid Medicaid Medicare 52

Medval Compliance Blog

MARCH 10, 2022

by Frank Fairchok, Vice President of Medicare Reporting Services. Last week, the Centers for Medicare & Medicaid Services (CMS) advanced the rulemaking process in two long-awaited areas. 0938-AT85 – Medicare Secondary Payer and Future Medicals (CMS-6047). 0938-AT85 – Medicare Secondary Payer and Future Medicals (CMS-6047).

US Department of Health and Human Services 52

US Department of Health and Human Services Medicare Medicare Medicaid 52

McGuire Wood

OCTOBER 2, 2023

According to the DOJ press release, from January 2013 to July 2018, Oliver Street, doing business as U.S. The disclosure noted that claims for certain referred services were submitted for payment to Medicare, thus invoking the reach of the implicated federal laws. CMS Voluntary Self-Disclosure.

Fraud 52

Fraud Governance Compliance Medicare 52

Innovaare Compliance

APRIL 7, 2024

The Centers for Medicare & Medicaid Services (CMS) officially announced capitation rates for Medicare Advantage (MA) plans for CY 2025 – average increase of 3.7% In total, gross spending under Medicare Part D was $240 billion in 2022; Ozempic accounted for 2% of this amount, before rebates [5]. billion [4].

Medicare 59

Medicare Medicare COVID-19 Medicaid 59

Healthcare Law Blog

MARCH 25, 2022

In February 2018, a district court in New Mexico vacated HHS’s risk-adjustment rules for benefit years 2014 through 2018 to the extent the rules relied on the third step of HHS’s methodology. Then, in July 2018, HHS announced it would republish the previously adopted risk-adjustment rule for the 2017 benefit year.

ACA 52

ACA US Department of Health and Human Services Health Insurance Medicaid 52

Innovaare Compliance

APRIL 7, 2024

The Centers for Medicare & Medicaid Services (CMS) officially announced capitation rates for Medicare Advantage (MA) plans for CY 2025 – average increase of 3.7% In total, gross spending under Medicare Part D was $240 billion in 2022; Ozempic accounted for 2% of this amount, before rebates [5]. billion [4].

Medicare 52

Medicare Medicare COVID-19 Medicaid 52

Innovaare Compliance

FEBRUARY 9, 2021

Annually, the Centers for Medicare & Medicaid Services (CMS) releases star ratings, which measure the quality of care health plans deliver for its members. Medicare Advantage and Part D) for a comprehensive assessment of a health plan’s performance. Read More – Medicare Star Ratings Changes 2021 . Industry trends.

Medicare 40

Medicare Medicare Medicaid Medicaid 40

HIT Consultant

SEPTEMBER 14, 2022

What You Should Know: – The full automation of prior authorization at the point of care leads to improved member experiences, enhanced outcomes, ongoing compliance, and reduced administrative burden. in 2018 to $10.92 8487) aimed at simplifying the prior authorization process.

Medicaid 52

Medicaid Medicaid Medicare Medicare 52

Health Care Law Brief

JUNE 26, 2022

Under the traditional, or fee-for-service (FFS), Medicare program, CMS directly pays providers a predetermined rate for the items and services furnished to patients under Medicare Parts A and B. 7, 2018), reconsideration denied Jan. CMS’s Payments to MA Plans. at § 1395w-23(b)(4)(D). 29844, 29921 (May 23, 2014). 3d 173 (Sep.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

HIT Consultant

APRIL 20, 2022

Since the passage of the Medicare Improvements for Patients & Providers Act in 2008, the U.S. As part of this VBC mode l, hospitals and health systems must store, track, and analyze a large amount of quality-related data for compliance and reimbursement purposes. In 2018, Milliman issued an updated report with more recent data.

Medicare 92

Medicare Medicare Telemedicine Medicaid 92

Health Law RX

DECEMBER 21, 2023

According to OCR, the initial unauthorized access occurred on April 1, 2017, but DMS did not detect it until December 24, 2018, when ransomware was used to encrypt the practice’s files. Maintain, review, and revise, if necessary, written policies and procedures to ensure compliance with the HIPAA Rules, particularly the HIPAA Security Rule.

HIPAA 52

HIPAA Ransomware Compliance Medicaid 52

HIPAA Journal

JUNE 26, 2023

In the context of HIPAA enforcement discretion, the Secretary can waive sanctions and penalties that result from non-compliance with the following standards of the Privacy Rule: 164.510 – Uses and disclosures of Protected Health Information requiring an opportunity for the individual to agree or object.

HIPAA 74

HIPAA COVID-19 COVID-19 Vaccine Public Health 74

HIPAA Journal

JULY 24, 2023

Healthcare providers participating in federal healthcare programs are advised to regularly check the HHS OIG Exclusions List to avoid penalties for non-compliance with §1128 of the Social Security Act. The list now covers more than just Medicare and State Health Care Programs and includes programs such as CHIP, TRICARE, and Veterans Affairs.

Fraud 52

Fraud Medicare Medicare Medicaid 52

HIT Consultant

OCTOBER 21, 2022

The Centers for Medicare & Medicaid Services (CMS) is evaluating hospitals’ antibiotic stewardship and more recently, in the area of sepsis, hospitals’ compliance with CMS’ 1-h and 3-h sepsis resuscitation guidelines. Every six months, CMS puts out a compliance score for each hospital. They are asking: how do we standardize?

Hospitals 89

Hospitals FDA Compliance COVID-19 89

Healthcare Law Today

DECEMBER 8, 2022

On November 28, 2022, the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality issued a memorandum to State Survey Agency Directors stating that hospitals risk Condition of Participation (CoP) violations for failure to adequately respond to and prevent incidents of workplace violence.

Hospitals 111

Hospitals Nurses Nursing Homes Medicaid 111

HIT Consultant

NOVEMBER 24, 2022

Health plans could, for example, consider covering OTC hearing devices as part of the hearing benefits package provided to their Medicare Advantage plan members. 4 And compliance decrease over time. . For Medicare Advantage plans, a positive member experience is critical in achieving 5-star ratings. million U.S.

FDA 85

FDA Public Health Medicare Medicare 85

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. A great free modifier resource to share with you is the CMS Medicare Administrative Contractor (MAC) “WPS” learning center with on-demand training materials. If in doubt, check it out.

Fraud 52

Fraud Medicare Medicare Compliance 52

Med-Net Compliance

NOVEMBER 8, 2022

The inspection objective was to determine whether the direct care licensed nursing hours recorded at the nursing home supported the hours submitted to the US Centers for Medicare & Medicaid Services (CMS) in compliance with federal requirements.

Nursing Homes 59

Nursing Homes Nurses US Department of Health and Human Services Licensing 59

HIPAA Journal

JANUARY 31, 2024

As the chart shows, healthcare security breaches are occurring twice as often as in 2017/2018, with two large healthcare data breaches reported each day on average in 2023. Just a few years ago it was alarming that large healthcare data security breaches were being reported at a rate of one a day. reduction from the previous year.

Ransomware 128

Ransomware HIPAA Hospitals Compliance 128

HIPAA Journal

JANUARY 23, 2024

Theranos and Homes denied the allegations and threatened to sue Carreyrou; however, in 2018, Homes stepped down from her position as CEO, and following an FBI investigation the company was shut down. The FDA launched an investigation into Theranos that found that the allegations in Carreyrou’s article were correct.

Fraud 82

Fraud FDA Medicaid Medicaid 82

Florida Health Care Law Firm

DECEMBER 9, 2021

The Rule does not apply to people with coverage through Medicare, Medicaid, Indian Health Services, Veteran Affairs Health Care or TRICARE as these programs already contain protections against high medical bills. Bans balance billing for emergency services.

Medical Billing 40

Medical Billing Medicare Medicare Compliance 40

Provider Trust

JANUARY 26, 2022

Let’s start with the role of the OIG, which is tasked with ensuring that dollars for federal healthcare programs such as Medicare, Medicaid, CHIPS, and TriCare, as well as other healthcare federal grant monies, are judiciously spent and awarded as reimbursements for quality care that is not fraudulent. Department of Justice (DOJ), the U.S.

Fraud 52

Fraud US Department of Health and Human Services Medicaid Medicaid 52

Florida Health Care Law Firm

FEBRUARY 22, 2022

In yet another take-down of an illicit scheme to defraud the Medicare Program and ChampVA, as well as other insurers, Patsy Truglia has been sentenced to 15 years in federal prison. million from Medicare, ChampVA, and insurance using a scheme of telemarketing, telemedicine, and multiple DME providers or “store fronts.”.

Telemedicine 52

Telemedicine Medicare Medicare Fraud 52

Hall Render

JULY 12, 2023

If a deemed hospice fails to meet the Medicare requirements or shows continued condition-level noncompliance, deemed status is generally removed and oversight is placed under the SA. Selected hospices either successfully complete the SFP program or are terminated from the Medicare program. of hospice providers reported data.

Medicare 40

Medicare Medicare Nursing Homes Fraud 40