$29M Overpayment Case: A Costly Lesson in Compliance
Healthicity
MARCH 3, 2025
In the latest Deeper Than the Headlines episode, we dive into a healthcare compliance case that resulted in a $29 million settlement.
What Payers Need to Know to Stay Ahead in 2025
MRO Compliance
JANUARY 16, 2025
For payers, investing in interoperability is more than meeting regulatory compliance, it creates a future where patient data follows seamlessly, improving care coordination and reducing administrative burdens. Many claims analysts feel that chasing down overpayments feels like plugging leaks in a sinking boat.
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The 60-Day Rule: What Healthcare Professionals Need to Know
Healthicity
MARCH 6, 2025
The 60-day rule under the Affordable Care Act is one of the most important compliance regulations for healthcare providers accepting Medicare or Medicaid payments. It requires organizations to identify, report, and return any overpayments within 60 days of discovery.
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The Final Rule: How to Prevent $389,000 in Medicare Overpayments
Healthicity
FEBRUARY 8, 2022
In a recent audit of a New York hospital, the HHS OIG identified overpayments. New York Hospital to Pay $389,000 to Medicare.
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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.
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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. The overpayment rate for definitive drug testing for 22 or more drug classes was over 71%. Review at-risk payments made to at-risk providers during and after the OIG’s audit period and recover any overpayments.
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Healthcare Compliance Experts: This Webinar Workshop Could Save Your Hospital Millions of Dollars in Overpayments
Healthicity
MARCH 4, 2022
The OIG continues to perform focused audits on hospital claims using billing data from thousands of hospitals.
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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.
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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.
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Breaking Down the OIG’s First Industry-Specific Guidance
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. CJ Wolf, MD, M.Ed.
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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. The Overpayment Rule. The Overpayment Rule, set forth at 42 U.S.C. 29844, 29921 (May 23, 2014). See UnitedHealthcare Insurance Co. 3d 173 (Sep.
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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. Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs. Background RADV audits are the main tool that CMS uses to correct overpayments made to MAOs.
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New York State OMIG Makes Regulatory Modifications to Compliance Program Requirements
Health Law Advisor
AUGUST 25, 2023
It is axiomatic that New York State requires every Medicaid provider to have an “effective” compliance program. These regulations were proposed to implement portions of the New York State 2020-2021 Budget Bill amending the mandatory compliance program requirements. New York Social Services Law § 363-d.
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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.
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Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program
Healthcare Law Blog
FEBRUARY 3, 2023
New Subpart 521-1: Compliance Programs The adopted regulations represent substantial changes to 18 N.Y.C.R.R. Part 521 governing the implementation and operation of effective compliance programs for certain “required providers,” including, now for the first time, Medicaid managed care organizations (MMCOs). [1]
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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. Compliance officers can help protect revenue and reduce the risk of penalties by collaborating with the Finance and Reimbursement departments to navigate the dynamics of outlier payments and prospective repayment.
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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. These challenges account for 16% of overall denials, amounting to $17 billion from the sampled data.
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Fraud Indicators and Red Flags
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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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. More > Tags: Centers for Medicare & Medicaid Services , CMS , Department of Health & Human Services (“HHS”) , False Claims Act , health care industry , Health Care Law , Healthcare Compliance Issues , Medicare.
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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.
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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. That’s a 41% error rate with an extrapolated overpayment of?$269 Don’t let processes overwhelm clinical colleagues.
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Avoiding “Gotcha” Moments in Compliance
YouCompli
NOVEMBER 1, 2023
As compliance officers, we are continually placed in a position to influence the actions of others and help shape our organization’s compliance culture. One way to change that perception is to avoid creating “gotcha” moments when you’re working on a compliance-related matter. Here are four tips that will help.
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Avoiding Red Flags: Finding the Right Productivity Balance
Healthcare IT Today
NOVEMBER 22, 2022
Auditors may also perform technical audit reviews, medical necessity compliance reviews, and medical policy reviews. The payer could also recoup the overpayments from future visits. . Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. What Triggers Audits? . There are only so many hours in the day.
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Patient-Focused Elements of an Effective Healthcare Compliance Program
YouCompli
FEBRUARY 1, 2023
Using the OIG’s seven elements as a guide to delivering better patient care Healthcare Compliance professionals tend to focus, rightfully so, on the regulations and organization requirements around providing quality patient care and keeping patients safe. Compliance officers have three main roles in this.
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Healthcare Compliance is Everyone’s Business: Legal, Internal Audit, Human Resources and Quality
YouCompli
MAY 17, 2023
Sharon Parsley, JD, MBA, CHC, CHRC contributes a regular post on compliance officer effectiveness for the YouCompli blog. What does it really take to ensure that an organization has a mature, well-integrated, and high-performing Compliance function? Hopefully, both Compliance and Legal are involved in your contract approval processes.
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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?
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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. However, the overpayments for the years 2009 and 2010 totaled up to $173,000. Official Break Down of the Audit.
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OIG Issues Updated General Compliance Program Guidance: Overview of Key Elements & Changes
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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Compliance is Everybody’s Business: Clinical, Revenue Cycle, IT, Sales and Marketing
YouCompli
DECEMBER 14, 2022
Sharon Parsley, JD, MBA, CHC, CHRC contributes a monthly post on compliance officer effectiveness for the YouCompli blog. Many people in our discipline love the slogan “compliance is everybody’s business.” In the process, they became compliance champions. Seize every opportunity to demonstrate that compliance is not the police.
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CMS’s 60-Day Rule Impacts False Claims Act Liability
Hall Render
JANUARY 10, 2025
Background CMSs 60-Day Rule is a regulation under the Affordable Care Act (“ACA”) that requires health care providers and suppliers to report and return identified Medicare and Medicaid overpayments within 60 days of identifying them. Failure to comply can result in liability under the FCA. The rule is codified at 42 U.S.C.
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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? This short article provides a basic overview of this complex topic.
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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.
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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.
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New Safe Harbor and General Compliance Program Guidance Provides Opportunity for Buyers to Mitigate Litigation and Fraud Risk
Health Law RX
JANUARY 30, 2024
By maintaining a robust compliance program, healthcare companies are better able to identify potential red flags early and to prevent violations of fraud and abuse laws. The DOJ Announcement stresses the importance of investing in strong compliance programs for both the buyers and sellers in business transactions.
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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.
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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.
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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
MA plans will be required to have a Utilization Management Committee that conducts annual reviews of policies to ensure compliance with the foregoing. Notable Omissions from Proposed Rule CMS declined to adopt previously proposed amendments to the standard for “identified overpayments” under Medicare Parts A, B, C, and D. See 42 U.S.C.
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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.
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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. Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim.
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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.
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Georgia Nursing Home Settles to Resolve Allegations of False Claims for Therapy Services
Healthcare Compliance Blog
MARCH 16, 2022
an overpayment), make all reasonable efforts to determine if inappropriate billing occurred, if any related overpayments exist, and if found, return the funds to Medicare within 60 days of identification. . Periodically audit to ensure that skilled rehabilitation services being provided to residents are reasonable and necessary.
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.
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Navigating CMS UPIC Audits: A Guide for Healthcare Organizations
Compliancy Group
FEBRUARY 7, 2024
For healthcare organizations, understanding UPIC audits and preparing for them is essential to compliance. Through a combination of data analysis, investigations, medical reviews, and site visits, UPICs scrutinize healthcare providers and suppliers to ensure compliance with billing rules and the provision of medically necessary services.
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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. Integrating this strategy into your compliance culture can help your organization avoid penalties and deliver compliant patient care. For staff, compliance officers should support annual online FWA compliance training.
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