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.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

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.

Overpayments 126

Overpayments Overpayment Compliance Medicare 126

Healthcare IT Today

NOVEMBER 22, 2022

Finally, payers of all stripes may send documentation requests. An Advanced Document Request (ADR) is then followed by a list of beneficiaries and dates of service to be reviewed. The payer could also recoup the overpayments from future visits. . Optimize billing while navigating payer rules and maximizing payments.

Overpayments 111

Overpayments Overpayment Medicare Medicare 111

Health Law Advisor

FEBRUARY 2, 2023

For these years, CMS will limit payment recoveries to “enrollee-level adjustments,” i.e., the non-extrapolated overpayments identified in CMS RADV audits and Department of Health and Human Services Office of Inspector General (OIG) audits. CMS expects to recover a total of $4.7 This total includes $41.1

Medicare 98

Medicare Medicare Overpayments Overpayment 98

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.

Fraud 52

Fraud Medicare Medicare Compliance 52

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? How can your organization improve accuracy of HCC documentation?

Overpayments 52

Overpayments Overpayment Compliance Medicare 52

Healthcare IT Today

FEBRUARY 22, 2023

CMS requires chart reviews to catch overpayments. A common example where they can let a payment slip was cited by Bridgeford: If a patient has suffered from an amputation, this condition has to be documented every year. They’re valuable for many reasons.

Medicare 118

Medicare Medicare Overpayments Overpayment 118

HIT Consultant

SEPTEMBER 27, 2024

billion in overpayments to MA plans with this new audit methodology over the next ten years. Improving coding training and best practices Achieving better risk adjustment results starts with ongoing training efforts and proactively planning for overpayments. million in overpayments to just one plan over the course of two years.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

Healthcare Compliance Blog

MARCH 16, 2022

Document that these trainings occurred, and file the signed documents in each employee’s education file. 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. .

Nursing Homes 59

Nursing Homes Nurses Overpayments Overpayment 59

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.

Overpayments 40

Overpayments Overpayment ACA Medicare 40

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? Then, why was I criticized?

Fraud 52

Fraud Compliance Overpayments Overpayment 52

Healthcare Law Blog

FEBRUARY 3, 2023

OMIG’s new Compliance Program Guidance outlines several best practices and provides examples of documentation that OMIG believes Medicaid required providers should maintain to demonstrate that the they have adopted, implemented and maintain effective compliance programs that meet each of the 7 elements specified in the regulations.

Medicaid 52

Medicaid Medicaid Compliance Overpayments 52

McBrayer Law Blog

NOVEMBER 18, 2020

The estimated overpayment as a result of these coding errors is a reported $1 billion. The increased payer audits will result in severe financial damage for hospitals and other MS-DRG applicable entities if they do not mitigate coding and documentation risks.

Compliance 52

Compliance Overpayments Overpayment Medicare 52

Health Care Law Brief

APRIL 12, 2023

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. The Social Security Act requires “a person” who has received an overpayment to report and return the overpayment no later than 60 days after being “identified.”

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Healthcare Compliance Blog

APRIL 14, 2022

Document that these trainings occurred, and file each signed document in the employee’s education file. an overpayment), make all reasonable efforts to determine if the skilled level of care is appropriate before submitting a claim to Medicare. To avoid a “reverse false claim” (i.e.,

Medicare 59

Medicare Medicare Overpayments Overpayment 59

HIT Consultant

MARCH 20, 2024

The HHS Office of Inspector General (OIG) recently reported that, from October 2014 through December 2016 , 153 audit reports were issued containing 193 overpayment recoveries totaling $648 million, largely due to errors in medical documentation.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

The Health Law Firm

JULY 26, 2012

According to the audit, the hospital complied with Medicare billing requirements for the documentation majority of inpatient and outpatient claims. However, the overpayments for the years 2009 and 2010 totaled up to $173,000. Official Break Down of the Audit.

Medicare 40

Medicare Medicare Compliance Overpayments 40

Healthcare IT Today

FEBRUARY 2, 2023

In turn, this should also build more meaningful connections between providers and members as they work together to document and promote patient health. Missed conditions: If a member has a condition that is being treated or monitored, it must be documented. did the provider education improve documentation?).

Medicare 69

Medicare Medicare Overpayments Overpayment 69

Medisys Compliance

NOVEMBER 26, 2024

Here are some essential aspects: Documentation Requirements: Detailed medical records supporting the necessity of skilled care. Common Issues Impacting SNF Billing Compliance Improper Payments: Errors in coding or documentation can lead to overpayments or denials. Claims must reflect the terms of insurance contracts accurately.

Compliance 52

Compliance Medical Billing Outsourcing Medicare Medicare 52

Health Care Law Brief

MAY 11, 2022

Covered employers will be required to retain records of claims and substantiating documentation for a period of no less than six years. The Medicaid inspector general, in coordination with the Commissioner of Health, shall be authorized to conduct audits, investigations, and reviews of employers required to submit claims under the provision.

Medicaid 97

Medicaid Medicaid Overpayments Overpayment 97

Healthcare Compliance Blog

JUNE 9, 2022

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. 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

Innovaare Compliance

MARCH 1, 2022

6] Improper payments can be overpayments and underpayments. Overpayments put an MAO at risk in a bid and a one-third financial audit while underpayments consume valuable staff time in resolving provider disputes and can also be a jeopardy in a one-third financial audit.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Med-Net Compliance

OCTOBER 21, 2022

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. Document that these trainings occurred and file the signed document in each employee’s education file.

Fraud 59

Fraud Compliance Medicare Medicare 59

YouCompli

FEBRUARY 22, 2023

They found the facility correctly billed 17 of the 120 but incorrectly billed the remaining 103 claims, which totaled over $580,000 in overpayments. For example, 10 claims included charges for codes that were not supported by the medical documentation. Return illegitimate reimbursement and overpayments quickly.

Compliance 52

Compliance US Department of Health and Human Services Overpayments Overpayment 52

Health Care Law Brief

APRIL 3, 2023

In the Advance Notice, CMS predicted that the changes to the risk scores and HCC updates will help prevent overpayments by improving the accuracy of payments made to MAOs. This would effectively make improper coding (due to unsubstantiated medical records or other reasons) an overpayment subject to the FCA. See 88 Fed. 6643 (Feb.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Healthcare IT Today

FEBRUARY 2, 2024

This reactive model leads to only ~70% of identified overpayments being recovered and/or corrected. Payers battle administrative overload caused by reconciling inaccurate payments and reprocessing claims to pay the accurate reimbursement amount. Providers navigate abrasive recoveries and revenue instability.

Payment Systems 78

Payment Systems Overpayments Overpayment Medical Billing 78

Compliancy Group

FEBRUARY 7, 2024

The outcome of these audits can range from repayment of overpayments to criminal prosecution in cases of fraud. How to Prepare for a UPIC Audit Preparing for a UPIC audit involves a proactive approach to compliance and documentation. Healthcare organizations can take several steps to prepare for a UPIC Medicare audit.

Fraud 52

Fraud Compliance Medicare Medicare 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. That’s a 41% error rate with an extrapolated overpayment of?$269 The majority of the errors were due to: Incomplete medical record documentation.

Compliance 52

Compliance Compliance Officers Overpayments Overpayment 52

YouCompli

NOVEMBER 1, 2023

Let’s imagine someone is conducting an audit involving the review of medical-necessity documentation for physical therapy services. After the audit, the person holds an exit conference with the director to discuss results – and reveals that all the claims involving their sample had missing documentation to support medical necessity.

Compliance 52

Compliance US Department of Health and Human Services Compliance Officers Overpayments 52

AIHC

OCTOBER 23, 2024

Document this information sufficiently for ease of copying into your final report. An auditor can gain much information by interviewing associates, observing activities or documenting evidence found in certain records. When Documenting the Report of Findings Never make assumptions. Create checklists to stay on track.

Compliance 52

Compliance Overpayments Overpayment Medicaid 52

Medisys Compliance

MARCH 7, 2022

You want unique documentation for each encounter, and it should stand out in your progress note. In the unfortunate event when you receive such overpayment demand letters, don’t acquiesce without conducting an analysis first. We ensure that you use accurate procedure codes and modifiers and maintain proper documentation.

Medical Billing 52

Medical Billing Medical Billing Outsourcing Overpayments Overpayment 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. The DOJ will also determine if there is sufficient communication to employees informing them about the compliance program and garnering commitment to its mission.

Compliance 52

Compliance Overpayments Overpayment Compliance Officers 52

Healthcare Law Blog

MARCH 2, 2023

Once CMS acknowledges receipt of a provider’s SRDP submission, the provider’s obligation to report and return overpayments within 60 days is suspended. Therefore, all documents in connection with the SRDP can be submitted electronically by email to 1877SRDP@cms.hhs.gov. See 42 C.F.R. 1003.140; 42 C.F.R. 401.305(f).

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

AIHC

MARCH 28, 2022

This includes any documentation submitted with the claim or through an additional documentation request. Special review of documentation, payer guidelines and often appealing the claim is required to obtain payment. This includes any documentation submitted with the claim or through an additional documentation request.

Medicare 52

Medicare Medicare Compliance Governance 52

Healthcare Law Blog

SEPTEMBER 28, 2023

Refresher on the RADV Final Rule The Final Rule will implement the following changes: CMS will extrapolate RADV audit findings beginning with payment year (“PY”) 2018, and will not extrapolate RADV audit findings for PYs 2011 through 2017, though it will continue to collect the non-extrapolated overpayments that are identified.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

Healthcare IT Today

MAY 5, 2023

For instance, if a provider bills for cancer genetic tests for 100 percent of the patients covered by the plan—such as tests for colorectal, prostate, lung and breast cancer (BRCA) genes—it would be worth reviewing whether medical documentation supports these tests. Look for providers that bill for tests outside their specialty.

Fraud 72

Fraud Medicare Medicare Overpayments 72

Physician Credentialing Company

DECEMBER 4, 2024

These errors commonly occur from misinterpretation of the CPT coding guidelines, lack of documentation, or incorrect use of the coding rules. If the provider spends more or less time than the minimum required, they can bill for the wrong code if time is not tracked and documented correctly during a visit.

Medical Billing 40

Medical Billing Overpayments Overpayment Electronic Medical Records 40