The Final Rule: How to Prevent $389,000 in Medicare Overpayments
Healthicity
FEBRUARY 8, 2022
New York Hospital to Pay $389,000 to Medicare. In a recent audit of a New York hospital, the HHS OIG identified overpayments.
Compliance Medicare Overpayments 
These are the compliance issues providers should be preparing for, post-PHE
Healthcare IT News - Telehealth
JUNE 8, 2022
based attorney in the health law practice of Baker, Donelson, Bearman, Caldwell & Berkowitz about what providers should be doing to ensure compliance when the PHE finally sunsets. What do you see as the primary compliance issues providers will have to contend with? If Medicare coverage requirements for telehealth services (e.g.,
Join 26,000+
Insiders
Sign Up for our Newsletter
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Trending Sources
Understanding Basics of Medicare Overpayment
Medisys Compliance
JULY 5, 2022
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. Medicare Overpayment Collection Process.
Overpayment 
52
52 
Medicare Advantage Overpayments: Are You Ready for RADV Audits?
Innovaare Compliance
DECEMBER 14, 2023
In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage plans, particularly in the areas of compliance and risk assessment. CMS’s Role and the RADV Audits Program Medicare Advantage overpayments have become alarmingly problematic in the private payer program.
Overpayment 52
52 
Healthcare Compliance Risks with Urine Drug Testing Overpayments
YouCompli
MARCH 22, 2023
There has been significant enforcement over the last couple years relating to overpayments for UDT. According to the OIG, prior error rate testing has suggested an improper payment rate of almost 30% for Medicare. The overpayment rate for definitive drug testing for 22 or more drug classes was over 71%.
Overpayment 52
52 
The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule
Health Care Law Brief
JUNE 26, 2022
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. Congress also required CMS to use the “same methodology” to calculate the costliness of insuring a beneficiary in the MA program and in FFS Medicare.
Overpayment 52
52 
SNF Billing Compliance Made Simple
Medisys Compliance
NOVEMBER 26, 2024
Skilled Nursing Facility (SNF) billing compliance is a critical aspect of healthcare revenue cycle management, ensuring accurate reimbursement and adherence to Medicare regulations. As healthcare providers navigate the complexities of SNF billing, maintaining compliance is essential to avoid penalties, denials, and financial losses.
Compliance 52
52 
2023 Benchmark Report: Healthy Bottom Lines are Reliant on Cross-Functional Team Collaboration, Technology, & AI Investments
Healthcare IT Today
JANUARY 17, 2024
External Audits Surge Among the report’s standout findings is the significant uptick in external payor audits in 2023, a result of escalating federal government efforts to address the overpayments made in the past two to three years. Moreover, extended adjudication times (29-35 days) for initial responses to claims impacted cash flows.
Overpayment 126
126 
Avoiding Red Flags: Finding the Right Productivity Balance
Healthcare IT Today
NOVEMBER 22, 2022
The number of Medicare TPEs and commercial payer take-back audits alone is skyrocketing. They also look to flag “items and services that have high national error rates and are a financial risk to Medicare.” Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. Tricare and Medicare).
Overpayment 111
111 
Medicare Compliance Review of West Florida Hospital in Pensacola
The Health Law Firm
JULY 26, 2012
On July 2, 2012 the Officer of Inspector General (OIG) released its Medicare compliance review of West Florida Hospital in Pensacola. According to the audit, the hospital complied with Medicare billing requirements for the documentation majority of inpatient and outpatient claims. Official Break Down of the Audit.
Medicare 40
40 
CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments
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.
Overpayment 40
40 
Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough
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.
Compliance 52
52 
Compliance Risks Associated with Outlier Payments
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. The CCR is determined by a hospital’s cost report that is reconciled with the local Medicare contractor.
Compliance 52
52 
Posthospital SNF Care in Indiana Generally Met Medicare Level-of-Care Requirements
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.
Medicare 59
59 
Department of Justice (DOJ) Evaluation of Corporate Compliance Programs
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.
Compliance 52
52 
2024 Final Rule: CMS Announces More Changes to Medicare Advantage but Declines to Reform the “60 Day Rule”
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
52 
OIG Findings on Overpayments at Critical Access Hospitals
Healthicity
NOVEMBER 29, 2022
Health and Human Services Office of Inspector General (OIG) recently issued a report concluding that Medicare and patients combined overpaid more than a million dollars for the same professional services provided at critical access hospitals (CAH). Who Bills for Professional Services?
Overpayment 52
52 
Monitor Improper Payments for Part C and Part D with Medicare Audit and Monitoring Software
Innovaare Compliance
MARCH 1, 2022
The monthly premium for Medicare Part B rose 14.5%, from $148.50 By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1] By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1]
Medicare 52
52 
A million-dollar healthcare compliance monitoring mistake
YouCompli
OCTOBER 26, 2022
Helping our clinical colleagues feel the urgency of compliance monitoring can be a huge challenge. And the Compliance team simply doesn’t have the clinical expertise to own the monitoring of these requirements. The review found providers often did not meet the Medicare billing requirements – a whopping 83 of 200 were in error.
Compliance 52
52 
Conducting Internal Risk Adjustment Coding Audits
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? Medicare & the OIG are performing Risk Adjustment audits, are you?
Overpayment 52
52 
OIG Issues Highly Anticipated Industry Segment-Specific Compliance Program Guidance for Nursing Facilities
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.
Nurses 40
40 
Navigating CMS UPIC Audits: A Guide for Healthcare Organizations
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?
Fraud 52
52 
The Trebling Effect of (Some) False Claims Act Trials
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.
Overpayment 52
52 
Finding Success Amid Complexity: 3 Payer Strategies for Better Risk Adjustment Results
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.
Overpayment 52
52 
OIG Posts False Claims Act Settlements for FY 2022 Q1–Q4 on the Risk Spectrum
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.
Fraud 59
59 
Georgia Nursing Home Settles to Resolve Allegations of False Claims for Therapy Services
Healthcare Compliance Blog
MARCH 16, 2022
In a March 11, 2022, release by the Northern District of Georgia’s Office of the Department of Justice, it was reported that an investigation determined a Georgia nursing home knowingly submitted claims for unreasonable, unnecessary, and unskilled services for Medicare patients. This amount was based on the nursing home’s ability to pay.
The Importance of a Corporate Integrity Agreement
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.
Compliance 52
52 
Pitfalls of the “Pay and Chase” Model: How to Maintain Better Payment Integrity
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.
Overpayment 52
52 
Post-Acute Compliance Program Update: OIG Proposes Amendments to Exclusion Rules
Hall Render
DECEMBER 11, 2024
OIGs new Industry Segment-Specific Compliance Program Guidance For Nursing Facilities (Nursing Facility ICPG) for nursing home members of the health care compliance community emphasizes the importance of staff screening and exclusion checks. Information about the LEIE may be found on the OIGs Exclusions page. Under 42 CFR Sec.
Compliance 40
40 
Improving Patient Care With a “Prevent, Detect, Report” Strategy
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.
Preventing Genetic Testing Fraud: 5 Actions for Health Plans
Healthcare IT Today
MAY 5, 2023
The following is a guest article by Erin Rutzler, Vice President of Fraud, Waste, and Abuse at Cotiviti In Delaware, more than 250 Medicare patients underwent unnecessary genetic testing based on telehealth consultations that often lasted less than two minutes— costing Medicare thousands of dollars per patient.
Fraud 72
72 
Increasing Enforcement of Modifier Codes
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. This system of edits is called the National Correct Coding Initiative, or NCCI.
Compliance 52
52 
Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
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.
Fraud 52
52 
OIG Revises Self-Disclosure Protocol
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.
Overpayment 40
40 
The Power of a Quality Review: Your Best Defense Against OIG Audits
Healthcare IT Today
FEBRUARY 2, 2023
As proof, several health plans have been making headlines for coding errors and other issues that surfaced during audits: In just the third quarter of 2022, at least four audits have specifically targeted Medicare Advantage plans. The New York Times claimed eight of the 10 largest Medicare Advantage insurers had padded their bills.
Medicare 69
69 
Pennsylvania Man Excluded from All Federal Healthcare Programs for 22 Years
Healthcare Compliance Blog
JUNE 9, 2022
Between 2017 and 2019, the man, through a group of pain clinics he controlled, caused the submission of false claims for payment to Medicare. HHS-OIG will continue to work with the US Attorney’s Office to ensure the integrity of the Medicare Trust Fund.”. He is awaiting sentencing on those charges.
Part 2: Understanding How Payers Deny Claims
AIHC
MARCH 28, 2022
The complex Medicare appeals process is used to demonstrate the importance of appealing claims denied in an audit. The learning objective of this lesson is to help you become familiar with the Medicare Claims Review Program (MCRP). Other payers mirror Medicare’s program. Audited by a payer? What is an “improper” payment?
Medicare 52
52 
Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
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.
Fraud 52
52 
CMS Streamlines Stark Law Self-Referral Disclosure Protocol (SRDP)
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.
Overpayment 52
52 
Introduction to Telebehavioral Health
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. Medicare covers many telebehavioral and telemental health services including audio-only services.
COVID-19 59
59 
Fundamentals of a Healthcare Internal Business System Audit
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.
Compliance 52
52 
Discover what’s new for CMS Program Audit ODAG Protocol in 2022
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.
Overpayment 52
52 
Part 3: Audit Documentation to Avoid Potential Appeal Consequences
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
52 
2018 Medicare Fee-For-Service improper payment rate is lowest since 2010
CMS.gov
NOVEMBER 16, 2018
2018 Medicare Fee-For-Service improper payment rate is lowest since 2010. Administrator, Centers for Medicare & Medicaid Services. 2018 Medicare Fee-For-Service improper payment rate is lowest since 2010 Significant progress in saving $4.59B in estimated improper payments for the Medicare Fee-For-Service program.
Medicare 20
20 
Let's personalize your content