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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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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YouCompli

FEBRUARY 22, 2023

Raising prices on your hospital’s chargemaster can also raise your level of compliance grief. Most federal healthcare payors such as Medicare and Medicaid reimburse most providers on a prospective basis. Return illegitimate reimbursement and overpayments quickly. The government has a 60-day overpayment rule.

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Compliancy Group

FEBRUARY 2, 2024

Regarding compliance in the healthcare field, a practice, doctor’s office, or healthcare organization is constantly in the spotlight. A Department of Justice (DOJ) evaluation of a corporate compliance program involves an examination of its effectiveness in preventing and detecting instances of noncompliance.

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YouCompli

FEBRUARY 4, 2025

The HHS OIG recently issued its first Industry Segment-Specific Compliance Program Guidance, or ICPG , with many more expected. When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, it certifies the services were provided in compliance with all applicable statutes, regulations, and rules.

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Hall Render

JANUARY 10, 2025

On January 1, 2025, the Centers for Medicare and Medicaid Services’ (“CMS”) new 60-Day Rule became effective. However, under the updated rule, the obligation to report and return an overpayment begins upon identification, even if the exact amount is undetermined. The rule is codified at 42 U.S.C. 1320a-7k(d).

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Health Law RX

MARCH 30, 2023

Setting aside the incalculable impact that litigation can have on business operations, the statute itself anticipates repayment of the proven overpayment, treble damages, and exposure to a civil statutory penalty equal to a range between $13,508 and $27,018 per false claim. The defendants disagreed.

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C&M Health Law

DECEMBER 18, 2023

Department of Health and Human Services (HHS) published the General Compliance Program Guidance (GCPG) on November 6, 2023. The GCPG provides updated descriptions of the seven elements of an effective compliance program that health care entities have long relied upon. The Office of the Inspector General (OIG) of the U.S.

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HIT Consultant

SEPTEMBER 27, 2024

Risk adjustment requires constant attention to ensure accurate coding, timely regulatory compliance, and streamlined communications across the payer-provider continuum. billion in overpayments to MA plans with this new audit methodology over the next ten years. million in overpayments to just one plan over the course of two years.

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AIHC

SEPTEMBER 30, 2024

Written by Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS Does your compliance program include auditing and monitoring documentation and coding related to risk adjustments and your value-based care reimbursement? This short article provides a basic overview of this complex topic.

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Hall Render

NOVEMBER 25, 2024

Department of Health and Human Services (“HHS”) issued new Industry Segment-Specific Compliance Program Guidance For Nursing Facilities (“Nursing Facility ICPG”) for nursing home members of the health care compliance community. On November 20, 2024, the Office of Inspector General (“OIG”) for the U.S.

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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. For healthcare organizations, understanding UPIC audits and preparing for them is essential to compliance. What is the Purpose of UPIC Audits?

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Med-Net Compliance

OCTOBER 21, 2022

OIG cases against these parties are closed without evaluating the effectiveness of any efforts the parties have made to ensure future compliance with Federal healthcare program requirements. Issue: Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate.

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Hall Render

DECEMBER 11, 2024

The Proposed Rule would codify changes made by the Medicaid Services Investment and Accountability Act of 2019 (MSIAA), that added exclusion authorities related to misclassification and false information about outpatient drugs. Information about the LEIE may be found on the OIGs Exclusions page. Under 42 CFR Sec.

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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. See 42 U.S.C.

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Compliancy Group

FEBRUARY 29, 2024

By examining the purpose and regulatory mechanisms of these agreements, we can understand their role in ensuring compliance, promoting ethical conduct, and ensuring patient and employee safety. When a hospital, doctor’s office, or other healthcare organization is guilty of a regulatory or compliance violation , the U.S.

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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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Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 Poor dispute resolution could lead to compliance risks, reputational damage, and even loss of key providers. billion in healthcare fraud judgments and settlements.

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Provider Trust

JUNE 30, 2023

Maintaining the highest payment integrity standards helps payers avoid unnecessary payments, recover overpayments, and prevent fraud, waste, and abuse (FWA) in healthcare billing. In this model, healthcare claims are paid upfront, and then potential errors, overpayments, or fraudulent claims are “chased down” after payment has been made.

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Overpayments Overpayment Fraud Compliance 52

YouCompli

SEPTEMBER 13, 2023

Mitigating fraud, waste, and abuse (FWA) is taking on a new urgency for healthcare compliance professionals. 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.

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Florida Health Care Law Firm

DECEMBER 2, 2021

They believe that good faith disclosure of potential fraud and cooperation with OIG’s review and resolution process are indications of a robust and effective compliance program. The OIG clarified that using the SDP may mitigate potential exposure under Medicare and Medicaid 60-day reporting and returning requirements for overpayments.

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Overpayments Overpayment Fraud Medicare 40

YouCompli

SEPTEMBER 27, 2023

Two of the most significant healthcare compliance risks are medical coding and billing. Enforcement agencies like to “follow the money,” so to speak, and they often find it in medical claims submitted to government payors such as Medicare and Medicaid. In essence, they routinely double-billed for certain aspects of patients’ care. She

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Compliance Overpayment Overpayments Medicare 52

Innovaare Compliance

MARCH 24, 2024

The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1 Poor dispute resolution could lead to compliance risks, reputational damage, and even loss of key providers. billion in healthcare fraud judgments and settlements.

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Healthcare Compliance Blog

JUNE 9, 2022

In March of 2022, in a related matter, the man pleaded guilty to Healthcare Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the US Department of Health and Human Services between 2016 and 2020. Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate.

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US Department of Health and Human Services Overpayment Overpayments Medicare 59

Healthcare IT Today

FEBRUARY 2, 2023

These programs stress the importance of arriving at supportable diagnoses and charting the diagnoses effectively, which leads to more accurate submissions to the Centers for Medicare & Medicaid Services (or CMS). At $1,000 per code, these errors pointed to a possible overpayment of $64,000 for the identified members.

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Healthcare Law Blog

MARCH 2, 2023

Effective March 1 st , certain providers choosing to self-disclose Stark Law violations must use forms updated by the Centers for Medicare & Medicaid Services (“CMS”). Once CMS acknowledges receipt of a provider’s SRDP submission, the provider’s obligation to report and return overpayments within 60 days is suspended. See 42 C.F.R.

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Overpayment Overpayments Medicare Medicare 52

Innovaare Compliance

MARCH 1, 2022

1] The Centers for Medicare & Medicaid Services (CMS) has to establish an annual Part B premium that will adequately fund projected Medicare spending and maintain an adequate reserve in case actual costs are higher than estimated. 6] Improper payments can be overpayments and underpayments. in 2021 to $170.00

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AIHC

SEPTEMBER 5, 2023

Compliance Considerations for Best Outcomes Written in collaboration with the AIHC Volunteer Education Committee Delivering mental health services via telehealth has increased since the COVID-19 pandemic. Store-and-forward is less commonly reimbursed by Medicare and Medicaid programs.

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AIHC

OCTOBER 23, 2024

Internal audits can be an integral part of your corporate compliance program and used as an effective management system, whether it is focused on quality, safety or any other business element. The American Institute of Healthcare Compliance (AIHC) provides comprehensive training to certify healthcare auditors.

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Compliance Overpayment Overpayments Medicaid 52

Innovaare Compliance

JUNE 28, 2022

The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of CMS program audits in February 2022. Compliance Standard and Method of Evaluation are outlined in the protocol. . If you would like to explore how to efficiently and economically validate universe data, our compliance experts are eager to engage with you.

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AIHC

FEBRUARY 17, 2025

This article follows a road less-traveled by discussing the potential of audit managers knowingly skewing audit results causing unintended consequences within what appears to be a well-functioning compliance program. They stay silent on their responsibilities for compliance.

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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. Prior to appealing a Medicare, Medicaid, TriCare or other Federal Program claim, you should verify that your organization is compliant in this area ( click here ). If in doubt, check it out.

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AIHC

MARCH 28, 2022

The Medicare Fee-for-Service Compliance programs prevent, reduce, and measure improper payments in FFS Medicare through medical review. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.

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AIHC

MARCH 22, 2022

Monitor Reports for Inappropriate Write-Offs Are accounts reconciled and overpayments identified and handled properly? Revenue Cycle Managers are encouraged to obtain some training in compliance auditing. The post Part 1: Managing Denials Is Important to Good A/R Hygiene appeared first on American Institute of Healthcare Compliance.

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CMS.gov

NOVEMBER 16, 2018

Administrator, Centers for Medicare & Medicaid Services. One of my commitments as the Administrator of the Centers for Medicare & Medicaid Services (CMS) is to ensure we remain steadfast in our commitment to strengthen Medicare by making sure that tax dollars are spent appropriately. Fraud, waste, & abuse. Leadership. percent in 2018.

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Healthcare Law Blog

JANUARY 5, 2023

Just in time for the holidays, the Centers for Medicare and Medicaid Services (“CMS”) issued the Contract Year 2024 Proposed Rule for Medicare Advantage organizations (“MAOs”) and Part D sponsors (the “Proposed Rule”). We’ve summarized some of the key changes in the Proposed Rule. Comments on due February 13, 2023. Star Ratings.

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Hall Render

JUNE 30, 2023

for physician referral scheme In Los Angeles, hospital CEO pay could be capped Kaiser Permanente ratings affirmed amid healthy financial profile Nurses vote ‘no confidence’ in California hospital administration, board Nursing facility, management company settle physician kickback allegations for $3.8M

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