Healthcare IT Today

FEBRUARY 8, 2025

Muhammad Shujja at AltuMED outlined AI’s role in improving accuracy, detecting fraud, augmenting decision-making, and streamlining the RCM process – all essential to supporting modern business operations in healthcare. Read more… Harnessing AI for Smarter Medical Billing.

Medical Billing 60

Medical Billing Fraud Nurses Hospitals 60

Hall Render

MARCH 24, 2025

On February 11, 2025, the D.C. Under federal law, the public disclosure bar prohibits a relator from bringing an FCA lawsuit based on fraud that has already been disclosed through certain public channels. In United States ex rel. USCC Wireless Investment, Inc., relators filed a qui tam action under the False Claims Act (FCA).

Fraud 52

Fraud Governance 52

HIT Consultant

FEBRUARY 28, 2025

By implementing these strategies, healthcare providers can set the standard for patient experience in 2025 and beyond, delivering care that is not only efficient and accessible but also deeply rooted in trust and privacy.

Compliance 59

Compliance Fraud 59

Bill of Health

NOVEMBER 17, 2024

by Rebekah Ninan A recent lawsuit in the Southern District of New York has alleged that the health insurance company Anthem Blue and Cross Blue Shield violated state laws and committed fraud by maintaining “ghost networks” of mental health providers. 2025) research interests are focused on the intersection of health and the law.

Licensing 124

Licensing COVID-19 Fraud Health Care Access 124

HIPAA Journal

APRIL 16, 2025

Claims may also be submitted to recover extraordinary losses, such as losses due to identity theft and fraud, up to a maximum of $5,000 per class member. The settlement has received preliminary approval from the court, and the final fairness hearing has been scheduled for June 9, 2025. Bean of Siri & Glimstad LLP.

Ransomware 55

Ransomware Fraud Licensing HIPAA 55

HIPAA Journal

MARCH 11, 2025

The review of the compromised files was completed on January 22, 2025, and it was confirmed that they contained the personal and protected health information of 122,437 individuals who had previously received care at either the Center for Digestive Health or the Center for Digestive Endoscopy.

Department of Veterans Affairs 81

Department of Veterans Affairs Licensing Ransomware Fraud 81

AIHC

APRIL 22, 2025

Atkins, PhD, MSW, LMSW, CPC, CIGE The governments new whistleblower complaint portal launched in April 2025 emphasizes the importance of complying with regulations related to qui tam suits, OCR investigations and protecting the rights of employees submitting a tip or complaint internally or to authorities. Written by Dr. Stacey R.

Compliance 52

Compliance HIPAA Compliance Officers Fraud 52

Healthcare IT Today

MARCH 12, 2025

Given that credentialing errors and fraud contribute to more than $100 billion in annual healthcare fraud costs, ProviderLenz plays a critical role in improving data integrity and preventing abuse. Originally announced February 24th, 2025

Electronic Medical Records 52

Electronic Medical Records Fraud Compliance 52

HIT Consultant

APRIL 10, 2025

Healthcares vast network of providers, insurers, and third-party vendors makes it a lucrative target for email-based fraud and ransomware infections. As email security threats become more automated and difficult to detect, proactive defense strategies will be the key to protecting healthcare organizations in 2025.

Regulatory Compliance 66

Regulatory Compliance Ransomware Fraud Compliance 66

AIHC

FEBRUARY 24, 2025

Part 2: When Criminal Behavior Infiltrates Your Audit Program Written by Carl J Byron , CCS, CHA, CIFHA, CMDP, CPC, CRAS, ICDCTCM/PCS, OHCC and CPT/03 USAR FA (Ret) We Recommend Reading Part 1 Fraud Indicators and Red Flags When Audit Managers Knowingly Skew Audit Results as this article is Part 2, the rest of the story.

Fraud 52

Fraud Compliance Governance Compliance Officers 52

Hall Render

MARCH 12, 2025

On February 14, 2025, the United States Court of Appeals for the Fourth Circuit (the “Court” or “Fourth Circuit”) issued a significant ruling in United States ex rel. This decision ensures that whistleblowers can still bring new and distinct allegations of fraud even if similar cases were filed previously.

Fraud 52

Fraud Governance Medicaid Medicaid 52

Healthcare IT Today

FEBRUARY 13, 2025

For instance, Sarbanes-Oxley (SOX) followed the Enron fraud, updates to FISMA came after the 2015 Office of Personnel Management (OPM) breach, and the Securities and Exchange Commissions cybersecurity disclosure provisions were implemented after breaches at Equifax and SolarWinds.

Compliance 59

Compliance HIPAA Ransomware Fraud 59

Healthcare IT Today

APRIL 10, 2025

Fraud, waste, and abuse, patient and provider experience, claims review, utilization management, and prior authorization are all being addressed with AI. .” Singh says that health care organizations are accustomed to automation for administration, but are now exploring it for such clinical tasks as patient access, registration, and RCM.

Fraud 75

Fraud Hospitals 75

Healthicity

FEBRUARY 13, 2025

From fraud schemes to cybersecurity concerns, healthcare providers must remain vigilant. Telehealth has permanently changed the healthcare landscape, offering convenience and accessibility like never before. However, as technology evolves, so do compliance risks.

Compliance 52

Compliance Fraud Compliance Officers 52

Healthcare IT Today

MARCH 13, 2025

Jepsen and Kajanoff also discuss the prevalence of fraud in our interview. The situation in health care contrasts strongly with popular ride-sharing services, where you can usually get a driver within minutes and a relative can trace your route to make sure you arrived at your destination on time.

Medical Billing 78

Medical Billing Fraud Hospitals Medicaid 78

Healthcare IT Today

MARCH 26, 2025

These flexibilities were extended through December 31, 2025, but regulators have indicated that stricter rules may soon follow. The rise of telehealth has also led to increased scrutiny over prescription fraud and misuse. However, the lack of finalized guidelines leaves many telehealth companies in a regulatory gray area.

FDA 52

FDA Compliance Licensing Fraud 52

HIPAA Journal

MARCH 19, 2025

The Michigan-based aesthetic surgery provider detected unauthorized third-party access to its computer network on January 29, 2025. At the time of issuing notification letters on March 7, 2025, the Hand & Plastic Surgery Centre was unaware of any reports of identity theft or fraud as a result of the incident.

Fraud 85

Fraud HIPAA Health Insurance Nurses 85

Verisys

MARCH 6, 2025

Identifying Compliance Risks in Real Time AI-powered surveillance tools work around the clock, scanning data to catch red flags or suspicious patterns that indicate: Fraud Security threats Regulatory violations Credential discrepancies Take electronic health records (EHRs), for example. 2025 Healthcare Compliance Outlook. link] IBM.

Compliance 52

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

HIT Consultant

JANUARY 16, 2025

Fraud Detection: Through continuous monitoring, AI identifies anomalies that signal the potential of fraud. By allowing organizations to catch these issues early, they can avoid possible financial losses and reduce the time and cost involved in fraud investigations.

Fraud 52

Fraud 52

HIPAA Journal

MARCH 26, 2025

According to Sunflower Medical Group, the unauthorized access was identified and blocked on January 7, 2025. Notification letters were mailed to the affected individuals on March 7, 2025, and complimentary credit monitoring and identity theft protection services were offered to individuals whose Social Security numbers were involved.

HIPAA 64

HIPAA Health Insurance Fraud Licensing 64

HIT Consultant

MAY 15, 2024

By 2025, the compound annual growth rate of data for healthcare will reach 36%. For example, machine learning (ML) algorithms can be trained to identify patterns and anomalies in healthcare data, which can be particularly useful in detecting potential fraud or compliance violations.

Healthcare information Technology 105

Healthcare information Technology Fraud Compliance 105

Hall Render

JANUARY 10, 2025

A recent article predicted trends in the senior housing industry for 2025. Four states (NC, SC, TN and GA) will implement significant changes to their certificate of need regulations in 2025, which could impact health care facility planning and development within those states. at a cost to the District of $434M.

Nursing Homes 40

Nursing Homes Nurses Hospitals Fraud 40

HIT Consultant

SEPTEMBER 8, 2024

Furthermore, SLM integration can streamline real-time insurance eligibility processes thanks to NLP’s ability to detect fraud when used in processing claims. It’s projected that by 2025, 36% of the world’s data will be healthcare-related. Informed doctors mean effective treatments.

Doctors 115

Doctors Fraud Nurses Governance 115

Hall Render

JANUARY 8, 2025

He has also supported, advised and re-structured health system and community hospital governance as well as provided guidance on material health care fraud and abuse and other regulatory matters.

Governance 40

Governance Fraud Licensing Hospitals 40

Hall Render

AUGUST 1, 2024

On July 3, 2024, a federal court in Texas (“the Court”) issued a stay related to certain provisions of CMS’s Contract Year 2025 Medicare Advantage and Part D (“MAPD”) Final Rule (“2025 Final Rule”), which would change how agents and brokers are paid by Medicare Advantage (“MA”) and Part D plans.

Medicare 40

Medicare Medicare Fraud Governance 40

Hall Render

AUGUST 1, 2024

On July 3, 2024, a federal court in Texas (“the Court”) issued a stay related to certain provisions of CMS’s Contract Year 2025 Medicare Advantage and Part D (“MAPD”) Final Rule (“2025 Final Rule”), which would change how agents and brokers are paid by Medicare Advantage (“MA”) and Part D plans.

Medicare 40

Medicare Medicare Fraud Governance 40

MedTrainer

MARCH 17, 2025

In fact, 81% of respondents cited the speed and accuracy of verifications as the biggest credentialing challenge, according to a 2025 MedTrainer poll. Relying on copies or self-reported credentials increases the risk of fraud and errors. Its forcing a new standard of PSV credentialing.

Licensing 52

Licensing Compliance Fraud Governance 52

Hall Render

JANUARY 17, 2025

On January 15, 2025, the Department of Justice (DOJ) announced that it recovered over $2.9 Health care fraud remained a leading source of FCA settlements and judgments with over $1.67 COVID-19-Related Fraud. billion in False Claims Act (FCA) related settlements and judgments in the fiscal year ending September 30, 2024 (FY2024).

COVID-19 40

COVID-19 Fraud Compliance Medicare 40

HIT Consultant

DECEMBER 11, 2024

Recent analysis from PwC suggests that by 2025, commercial healthcare spending will increase to its highest level in 13 years. When systems are antiquated, and incentives are misaligned, fraud, waste, and abuse invariably follow. Yet, there are strong reasons to embrace innovation, not least due to financial imperatives.

Fraud 52

Fraud COVID-19 Governance 52

Healthcare IT Today

NOVEMBER 11, 2022

The American Medical Informatics Association began a project to reduce patient documentation to 25% of its current volume by 2025. I heard one anecdote suggesting that pulling forward could lead to fraud. Bloat in patient notes has been alarming doctors for some time.

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Doctors Nurses Electronic Medical Records Fraud 103

Health Law Advisor

JULY 14, 2023

Under the Implementation Plan this should be completed by September 30, 2025. As we have previously written , CIRCIA directs CISA to publish a notice of proposed rulemaking within 24 months of the date of the enactment of CIRCIA, and that a final rule should be issued no later than 18 months after publication of the proposed rulemaking.

Fraud 52

Fraud Regulatory Compliance Compliance Governance 52

Hall Render

MAY 10, 2024

On April 10, 2024, the Centers for Medicare & Medicaid Services (“CMS”) announced its plan to implement the Transforming Episode Accountability Model (“TEAM”), a new mandatory alternative payment model unveiled as part of the 2025 Hospital Inpatient Prospective Payment System proposed rule.

Medicare 40

Medicare Medicare Hospitals Medicaid 40

HIPAA Journal

MARCH 20, 2025

These statistics and graphs were last updated on March 21, 2025, and are based on data obtained from OCR on March 19, 2025. OCR Penalties for HIPAA Violations (2008 – 2025) Year Covered Entity Amount Penalty Type 2024 Oregon Health & Science University $200,000 Civil Monetary Penalty 2024 Warby Parker Inc.

HIPAA 109

HIPAA Ransomware Compliance Hospitals 109

Hall Render

DECEMBER 11, 2024

ET on January 31, 2025. The Proposed Rule would revise the definition of failure to grant immediate access to specify what would constitute a compelling reason, namely, that the requested material does not exist or is not at the location where the request is presented. Comments are due by 5:00 p.m.

Compliance 40

Compliance Licensing Nurses Medicaid 40

Healthcare Law Blog

MAY 16, 2022

CMS made clear, in proposing that all FIDE SNPs have exclusively aligned enrollment, CMS is requiring that all FIDE SNPs will be limited to full benefit dually eligible individuals beginning in 2025. Refining Definition for Fully Integrated and Highly Integrated D-SNPs (§§ 422.2 and 422.107).

Medicare 52

Medicare Medicare Medicaid Medicaid 52

Hall Render

NOVEMBER 28, 2023

These changes would be effective with the CY 2025 performance year and are intended to bring the expanded HHVBP model into alignment with HHQRP, as well as the measures that are publicly reported on Home Health Compare. Beginning with CY 2025, the baseline year will shift to CY 2023. Do those patterns appear strategic?

Medicare 40

Medicare Medicare Payment Systems Medicaid 40

Bill of Health

APRIL 15, 2025

Published April 15, 2025 Authors Robert James Horne Saverio V. The use of intermediaries also results in higher consumption rates which contributes to spending waste, fraud and abuse that makes up roughly 25 percent of all health care spending in the U.S. Plus, these intermediaries have not managed to solve medical illiteracy.

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Doctors Governance Informed Consent Nurses 162