Amazon expands drug subscription program to Medicare members
Healthcare Dive
JUNE 18, 2024
RxPass is now available to more than 50 million Medicare members after Amazon brought it into compliance with the insurance program’s regulatory standards.
How to Conduct Effective Compliance Audits
American Medical Compliance
OCTOBER 25, 2024
Compliance isn’t just a box to check—it’s a vital responsibility that safeguards patient well-being and protects organizations from significant financial losses. A powerful way to ensure this is through regular compliance audits. This is to confirm that staff are properly trained in compliance protocols.
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Navigating Medicare Billing: A Physician’s Guide
Medisys Compliance
MARCH 31, 2025
Introduction For many physician practices, Medicare beneficiaries represent a significant portion of their patient population. However, navigating the complexities of Medicare billing can be a challenging task, especially when considering its distinct differences from private insurance models.
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How Medicare Advantage Programs Can Address Social Risk and Improve Health Outcomes
HIT Consultant
DECEMBER 23, 2024
Brian Norris, Managing Director of Strategic Consulting at MedeAnalytics There are almost 33 million people enrolled in eligible Medicare programs. Nearly half are enrolled in Medicare Advantage (MA) plans, and that number is expected to continue its climb.
Simplify Screening for Excluded Providers
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Use this sample Exclusion Screening Checklist and Compliance Policy to evaluate and improve your organization’s compliance with the law. Payments from Medicare, Medicaid, and TriCare trigger screening requirements that may extend to employees, contractors, volunteers, board members, and network providers.
How AI Can Accelerate and Ensure Accuracy when Translating Medicare Advantage Materials
Healthcare IT Today
APRIL 4, 2025
Translation of member materials is an onerous burden for Medicare Advantage Organizations (MAOs). For Dual Special Needs Plans (DSNPs), compliance is even more complex as they must meet both Medicare and Medicaid translation requirements, supporting as many as 24 languages in some states.
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HEDIS Preparation Guide: 3 Essential Steps
MRO Compliance
FEBRUARY 3, 2025
For healthcare organizations, the HEDIS season, which typically spans February to May, requires a proactive approach to ensure data accuracy, compliance, and efficiency. Reminder of the audit process: According to NCQA , the HEDIS compliance audit contains two parts information system capabilities and HEDIS specification standards.
The Physician Payments Sunshine Act – Compliance in a Nutshell
AIHC
MARCH 31, 2025
The "Sunshine Act," officially known as the Physician Payments Sunshine Act, mandates those manufacturers of drugs, medical devices, and biologics report payments and transfers of value to physicians and teaching hospitals to the Centers for Medicare & Medicaid Services (CMS).
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Navigating QPP Reporting in 2025: Finding the Best Path for Your ACO
MRO Compliance
JANUARY 28, 2025
Choosing the right reporting method is critical to ensure compliance and maximize your ACOs return. Medicare Clinical Quality Measures (Medicare CQMs): Medicare CQMs focus solely on Medicare patients, leveraging claims-based data to identify measure populations.
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Medicare Counseling Coverage Explained
Medisys Compliance
MARCH 9, 2025
Understanding Medicare coverage for counseling can feel particularly challenging, but it is crucial. Many providers find themselves asking: What exactly does Medicare cover when it comes to outpatient mental health counseling services? This cornerstone of outpatient mental health care is generally well-covered by Medicare.
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Integrate Self-Awareness into Healthcare Compliance Programs: 18 Tips
YouCompli
APRIL 9, 2025
As compliance officers, we spend a lot of time focused on how others perform their jobs. However, being self-aware of how we do our own work is paramount for an effective compliance program. Incorporating self-awareness into your healthcare compliance program can significantly enhance its effectiveness. If not, why?
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Navigating the CMS 2025 Physician Fee Schedule Final Rule
MRO Compliance
NOVEMBER 21, 2024
The Centers for Medicare & Medicaid Services (CMS) 2025 Physician Fee Schedule (PFS) Final Rule brings notable updates to the Quality Payment Program (QPP), which will impact eligible clinicians, groups, virtual groups, subgroups, and APM entities. CMS’s 2025 Final Rule introduces both challenges and opportunities.
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Outsourced Billing Services for Podiatrists
Medisys Compliance
DECEMBER 19, 2024
From managing CPT codes for procedures like nail debridement and wound care to ensuring compliance with Medicares podiatry-specific guidelines, the billing process can be confusing. Compliance with Podiatry Billing Guidelines Staying compliant with constantly evolving guidelines is crucial.
Updated Compliance Program Guidance for Nursing Facilities
Compliancy Group
FEBRUARY 12, 2025
The Office of Inspector General (OIG) released an updated Nursing Facility Industry Compliance Program Guidance (ICPG) in November 2024 to assist nursing facilities in navigating the complex regulatory landscape and mitigating compliance risks. The ICP covers the areas listed below.
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Outsourcing Cardiology Billing for Medicare and Medicaid
Medisys Compliance
JANUARY 29, 2025
Add in the complexities of Medicare and Medicaid, and it can feel overwhelming. This article will explore how outsourcing cardiology billing for Medicare and Medicaid can streamline your operations, boost revenue, and free you to focus on delivering exceptional cardiac care. Missteps here can lead to claim denials or underpayments.
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OIG Compliance Program Guidance for Nursing Facilities
Compliancy Group
OCTOBER 28, 2024
Its compliance program guidance (CPG) has improved the efficiency and effectiveness of Medicare and many other federal programs. Last November, the OIG published industry-specific compliance guidance for 2024 for several healthcare subsectors, including nursing homes and facilities.
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An Overview of Healthcare Compliance Laws and Regulations
Compliancy Group
NOVEMBER 1, 2024
Anyone in this industry should know the healthcare compliance laws and regulations that guide how they do their jobs and provide quality care. Here’s your healthcare compliance 101 for the critical federal regulations all employees should know.
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Preventing Non-Compliance Consequences in Healthcare
Verisys
MARCH 6, 2025
In the healthcare industry, compliance with regulatory standards is not merely a requirement but a cornerstone of safe, effective, and ethical patient care. When healthcare organizations fail to meet compliance standards, the consequences can be severespanning legal and financial realms. What is Non-Compliance in Healthcare?
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Medicare Swing Bed Rules and Regulations for CAHs
Healthcare Blog
JANUARY 19, 2025
CMS Medicare Swing Bed Rules and Regulations for Critical Access Hospitals (CAHs) Critical Access Hospitals (CAHs) are the backbone of rural healthcare, providing essential services to underserved communities. Why Are Medicare Swing Bed Rules So Important to Follow? Prevent fraud and abuse of Medicare funds.
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Mastering Compliance in Federal Health Care Programs
American Medical Compliance
FEBRUARY 15, 2025
In the complex world of healthcare, maintaining compliance with federal regulations is crucial for the integrity of healthcare providers. “Mastering Compliance in Federal Health Care Program Billing, Coding, and Claims Training” is designed to equip you with the knowledge needed to navigate these complex systems with confidence.
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Code Red: Healthcare Cybersecurity in a Post-Chevron World
HIT Consultant
OCTOBER 22, 2024
These interpretations have led to the development of detailed guidelines and enforcement actions to ensure compliance. Making HPH-CPGs a Condition of Participation (CoP) for CMS : The Centers for Medicare & Medicaid Services (CMS) could require adherence to HPH-CPGs as a condition for participating in Medicare and Medicaid programs.
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Navigating the Medicare Reimbursement Cuts: A Radiology Practice Guide for 2025 and Beyond
Medisys Compliance
FEBRUARY 19, 2025
Billing Update: Medicare Radiology Reimbursement Cuts 2025 Effective January 2025, radiology practices nationwide are facing reduced Medicare reimbursements due to finalized changes in the Physician Fee Schedule. Now, in February 2025, these proposed rules are our current reality. Here are key steps you can take: 1.
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2024 DOJ False Claims Act Settlements in Healthcare Recover $1.67B
Compliancy Group
JANUARY 23, 2025
A classic example is Medicare fraud. Providers who bill Medicare for services they did not actually provide and who present the bill with the knowledge that the service was not performed have committed Medicare fraud. Medicare Advantage Matters Medicare Part C is the largest part of Medicare.
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Hospice Update: Surveyors Called to Identify Quality of Care Concerns and Potential Fraud Referrals
Hall Render
JANUARY 29, 2025
The Centers for Medicare & Medicaid Services (CMS) is reinforcing its emphasis on hospice quality of care and identifying fraud. Hospice surveys are performed before their initial certification for Medicare participation. Identifying Fraud : Detecting practices that jeopardize patient safety or Medicare program integrity.
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HubSpot announces HIPAA-compliant tools in public beta
Healthcare It News
JUNE 5, 2024
Enterprises managing compliance with privacy rules could piece together point solutions to get a single view of their customer, but the patchwork approach could disconnect teams and result in jumpy customer experiences. The nexus of technology and HIPAA compliance has evolved, however.
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Indiana Physician Fraud Conviction Highlights Compliance Risks
Hall Render
NOVEMBER 1, 2024
Health care fraud remains a significant focus for federal and state enforcement agencies, with particular attention placed on the integrity of Medicaid and Medicare billing. He was also ordered to pay $557,000 in restitution to Indiana Medicaid and Medicare. As such, providers should prioritize billing compliance.
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Post-Acute Compliance Program Update: OIG Recommendations on Medical Director Agreements and Roles
Hall Render
MARCH 4, 2025
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. Medical Directors in Nursing Homes 42 CFR 483.70(g) When the services are DHS for purposes of the PSL (e.g.,
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Three Tech Takeaways from RISE: Health Plans Focus on Engagement, Collaboration and Compliance
MRO Compliance
MARCH 20, 2023
Three Tech Takeaways from RISE: Health Plans Focus on Engagement, Collaboration and Compliance March 20, 2023 Health IT Answers by Beth Friedman, FINN Partners It has been said that wherever Medicare goes, so do all the rest of the payers.
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Required Training For Medicare-Enrolled Providers
MedTrainer
AUGUST 8, 2024
As of March 2024, over 67 million in the United States are Medicare beneficiaries. Medicare is the single largest payer for healthcare services in the United States. In FY2021, the Centers for Medicare and Medicaid Services ( CMS ) reported that Medicare processed more than 1.1 Here’s what you need to know.
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Healthcare Compliance for New Providers: Getting Started
American Medical Compliance
AUGUST 7, 2024
Notably, many of these incidents are preventable and could have been avoided with proper compliance measures. Compliance with healthcare regulations is crucial not only for avoiding legal repercussions but also for ensuring high standards of patient care and safety. It ensures its confidentiality and maintains security.
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What Payers Need to Know to Stay Ahead in 2025
MRO Compliance
JANUARY 16, 2025
To address these gaps, the Centers for Medicare & Medicaid Services (CMS) now mandates the use of FHIR-based APIs for data sharing. Such proactive engagement helps meet compliance standards, builds trust, and improves outcomes. Embracing Innovation and Change In 2025, the future belongs to those who adapt, innovate, and lead.
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How Staff Education in Healthcare Drives Excellence
Healthcare Blog
OCTOBER 31, 2024
Compliance with regulations is only possible when all clinical and non-clinical staff members have the proper training and support. Maintain Regulatory Compliance Non-compliance with just one regulation can put patients’ health and organizational operations at risk.
Physical Therapy Billing Units: Guide for Accurate Reimbursements
Medisys Compliance
MARCH 21, 2025
Accurately understanding physical therapy billing units is crucial for healthcare providers to ensure proper reimbursement and compliance. Be aware of Medicare’s physical therapy billing guidelines 2025, which emphasize the importance of justification in medical records when billing for multiple units. Thats a common mistake!
Telehealth Mental Health Billing 2025: Key Updates and Insights
Medisys Compliance
JANUARY 23, 2025
As we step into 2025, mental health providers must stay informed about evolving telehealth billing regulations to ensure compliance and optimize reimbursement. Will Medicare Stop Paying for Telehealth in 2025? Congresss decision reflects the growing recognition of telehealth’s role in improving healthcare access.
Medicare Advantage Organizations: 7 Ways to Ensure Your Document Management Platform Offers Full Automation
HIT Consultant
JANUARY 19, 2025
For Medicare Advantage Organizations (MAOs), the summer months have historically been defined by the high stakes, tight turnarounds and document management challenges of the Annual Enrollment Period (AEP). Sohail Malik, VP, Healthcare Solutions, Messagepoint, Inc.
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Payers share data, too! Seven information exchange insights to know
MRO Compliance
FEBRUARY 26, 2025
Likewise, payers are mandated by the Centers for Medicare & Medicaid Services to make member data available to external stakeholders via application program interfaces. Clinical data is a two-way street for payers. These organizations require timely and accurate patient data from their healthcare provider partners.
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Why Your Final MIPS Score Might Be Different from What You Expected – and What You Can Do About It
MRO Compliance
OCTOBER 31, 2024
During the performance year, there’s no way for providers or vendors to track or estimate cost data since CMS calculates it based on Medicare claims data after the performance period ends. If your final MIPS score is lower than expected, it’s natural to feel concerned, especially when Medicare payment adjustments are on the line.
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Understanding FWA Compliance in Healthcare
American Medical Compliance
MARCH 15, 2024
Among the various areas of compliance, Fraud, Waste, and Abuse (FWA) compliance stands out as a critical pillar. Therefore, for healthcare providers to prevent these charges from happening, understanding FWA compliance is essential. In this comprehensive guide, we delve into FWA compliance in healthcare.
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HHS proposes ‘powerful’ penalties for providers found information blocking
Healthcare Dive
OCTOBER 31, 2023
Regulators on Monday proposed a long-awaited rule tying payments for hospitals and doctor’s offices in three popular Medicare programs to compliance with data-sharing regulations.
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Hospice Update: CMS Pauses Implementation of the Hospice Special Focus Program for Calendar Year 2025
Hall Render
FEBRUARY 17, 2025
According to a statement released on the Center for Medicare and Medicaid Services (CMS) website, effective February 14, 2025, implementation of the Hospice Special Focus Program for calendar year 2025 has ceased so that CMS may further evaluate the program. The Final Rule added 42 CFR 488.1135 and created the SFP for hospice providers.
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Seven Elements of a Compliance Program
HIPAA Journal
MARCH 30, 2023
The seven elements of a compliance program are integrated processes organizations in all industries can adopt to help them develop a culture of compliance in the workplace. While the seven elements of a compliance program apply to all industries, they originated in the healthcare industry in the 1990s.
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Medicare Prescription Payment Plan (M3P) Implementation: Key Considerations for Part D Plan Sponsors and PBMs
Innovaare Compliance
JUNE 28, 2024
The upcoming Medicare Prescription Payment Plan (M3P), set to launch in January 2025, marks a significant shift in Medicare’s approach to prescription drug coverage. Understanding the Medicare Prescription Payment Plan M3P introduces a novel approach to managing prescription drug costs for Medicare beneficiaries.
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OCR will ease restrictions on telehealth tech during COVID-19
Healthcare IT News - Telehealth
MARCH 18, 2020
The HHS Office for Civil Rights announced on Tuesday that during the coronavirus pandemic it will use discretion when enforcing HIPAA-compliance for telehealth communications tools. WHY IT MATTERS. and Google G Suite Hangouts Meet. THE LARGER TREND.
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Comply with Privacy Rights to Avoid Unconsented Intimate Exams
AIHC
NOVEMBER 12, 2024
6] The letter also notes that obtaining informed consent for sensitive examinations is the standard of care and that OCR will continue to focus on provider compliance with HIPAA and proper informed consent. About the Author Gabriella Neff , RHIA, CHA, CHC, CHRC, CHPC is a Research Compliance Officer for H.
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