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).

Overpayments 107

Overpayments Overpayment Medicare Medicare 107

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. Future success requires more than managing denials to ensure timely payments.

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Overpayments Overpayment Compliance Medicare 122

Healthcare Law Blog

AUGUST 25, 2023

On August 21, 2023, the New York State Office of the Medicaid Inspector General (OMIG) announced updates to the Medicaid overpayment self-disclosure program, which now includes an abbreviated process for reporting and explaining overpayments that are considered routine or transactional in nature and have been already voided and adjusted.

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Overpayments Overpayment Medicaid Medicaid 52

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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Overpayments Overpayment Medicare Medicare 40

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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Medicare Medicare Overpayments Overpayment 59

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.

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Medicare Medicare Overpayments Overpayment 52

AIHC

APRIL 5, 2022

Only appeal claims when you have evidence and supporting documentation to substantiate your right to payment. Audit Coding, Billing and Documentation for Accuracy Insurance carriers and government contractors have the authority to review any claims at any time. However, it also includes documentation of a supporting diagnosis.

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Fraud Medicare Medicare Compliance 52

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]

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Medicare Medicare Overpayments Overpayment 52

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.

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Medicare Medicare Compliance Overpayments 40

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?

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Overpayments Overpayment Compliance Medicare 52

Healthcare Law Blog

SEPTEMBER 28, 2023

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. MAOs will be required to remit improper payments identified during RADV audits in a manner specified by CMS.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

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.

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Nursing Homes Nurses Overpayments Overpayment 59

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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Compliance Overpayments Overpayment Medicare 52

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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Overpayments Overpayment ACA Medicare 40

HIT Consultant

SEPTEMBER 27, 2024

Increasingly rigorous oversight from the Centers for Medicare & Medicaid Services (CMS) and Office of the Inspector General (OIG) are calling for better diligence, planning and administrative oversight for effective risk adjustment. billion in overpayments to MA plans with this new audit methodology over the next ten years.

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Overpayments Overpayment Medicare Medicare 52

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. Compliance requires strict attention to billing guidelines, proper coding, and understanding Medicare rules such as the Consolidated Billing (CB) policy.

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Compliance Medical Billing Outsourcing Medicare Medicare 52

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.”. Document that the trainings occurred and place in each employee’s education file.

US Department of Health and Human Services 59

US Department of Health and Human Services Overpayments Overpayment Medicare 59

AIHC

FEBRUARY 17, 2025

Introduction & Defining Terms The Office of Inspector General (OIG) provides compliance guidance documents for healthcare provider use. But its not technically a legal term or defined in any legal documents. But is the oversight of the audits manipulated to achieve particular performance goals?

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Fraud Compliance Overpayments Overpayment 52

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.

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Medicare Medicare Overpayments Overpayment 64

HIT Consultant

MARCH 20, 2024

The Centers for Medicare and Medicaid Services (CMS) estimated that for payment year 2018 alone , it will recover $428.4 To address these concerns and other matters, CMS announced significant regulatory changes to the Medicare Advantage (MA) program beginning in 2024. million (net) and $4.7

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Overpayments Overpayment Medicare Medicare 52

Med-Net Compliance

OCTOBER 21, 2022

Issue: Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability.

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Fraud Compliance Medicare Medicare 59

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. The Centers for Medicare and Medicaid Services (CMS) created UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid.

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Fraud Compliance Medicare Medicare 52

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?

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Medicare Medicare Compliance Governance 52

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.

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Fraud Medicare Medicare Overpayments 67

YouCompli

FEBRUARY 22, 2023

Most federal healthcare payors such as Medicare and Medicaid reimburse most providers on a prospective basis. This is why Medicare publishes its rules on their Inpatient Prospective Payment System (IPPS) or its Outpatient Prospective Payment System (OPPS). The inflated charges resulted in inappropriate outlier payments from Medicare.

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Compliance US Department of Health and Human Services Overpayments Overpayment 52

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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Overpayments Overpayment Medicare Medicare 52

AIHC

OCTOBER 23, 2024

Examples of these types of audits would be a Joint Commission, or CMS (Centers for Medicare and Medicaid Services) contractor audit. Document this information sufficiently for ease of copying into your final report. Independence of the audit organization is a key component of a third-party audit. Create checklists to stay on track.

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Compliance Overpayments Overpayment Medicaid 52

Compliancy Group

FEBRUARY 2, 2024

Tangible indicators of sufficient resources and effort include adequate staff assigned to conduct audits and document and analyze the results of the program’s efforts. A CIA allows a healthcare organization to meet certain obligations while maintaining participation in Medicare, Medicaid, and other federal funding programs.

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Compliance Overpayments Overpayment Compliance Officers 52

YouCompli

OCTOBER 26, 2022

Let’s now look at a real scenario that I encountered as a Compliance Officer that supports having Clinical leadership perform monitoring, document the monitoring, and report out the results. The review found providers often did not meet the Medicare billing requirements – a whopping 83 of 200 were in error. 269 million.?.

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Compliance Compliance Officers Overpayments Overpayment 52

Innovaare Compliance

JUNE 28, 2022

The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of CMS program audits in February 2022. This causes claims to providers to be paid incorrectly, which results in enrollees being overcharged for their coinsurance or delayed refund of overpayments. . 24 hours for expedited requests and 72 hours for standard).

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Overpayments Overpayment Compliance Medicare 52

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

Medicare Medicare Overpayments Overpayment 20

AIHC

SEPTEMBER 5, 2023

Keep in mind coding and documentation is extremely important for psychiatric services – consider registering for the Psychiatric Compliance – coding & documentation short course offered by the American Institute of Healthcare Compliance. Store-and-forward is less commonly reimbursed by Medicare and Medicaid programs.

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COVID-19 Telemedicine Informed Consent Compliance 59

AIHC

MARCH 22, 2022

Monitor Reports for Inappropriate Write-Offs Are accounts reconciled and overpayments identified and handled properly? To calculate, divide the dollar amount of accounts receivable that is greater than 120 days by the dollar amount of total current accounts receivable, then multiply by 100.

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Overpayments Overpayment Medicare Medicare 52

Hall Render

DECEMBER 11, 2024

Under the proposed language, the application of the cooperation mitigating factor would be based on documentation provided by an official involved in the underlying criminal proceedings rather than OIG’s later independent assessment of the criminal proceedings.

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Compliance Licensing Nurses Medicaid 40

Kaiser Health News

JUNE 29, 2022

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday. Medicare Advantage plans accept a set fee from the government for covering a person’s health care.

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Medicare Medicare Governance Overpayments 107

Health Care Law Brief

APRIL 3, 2023

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ( Rate Announcement ). 1395w-23): Medicare Advantage Organizations (MAOs) are paid a base rate by CMS. Risk Adjustment.

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Medicare Medicare Overpayments Overpayment 52

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”). Health Equity in Medicare Advantage. We’ve summarized some of the key changes in the Proposed Rule.

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