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.
Fraud Medicare Overpayments 
Retrieving Billions in Overpayments by CMS
Healthcare IT Today
FEBRUARY 17, 2023
Amid swirling accusations that Medicare Advantage Organizations (MAOs) are overbilling the U.S. government and calls for better oversight , the Centers for Medicare & Medicaid Services announced in early February that it would investigate overbilling by those plans. How can such overpayments be uncovered?
Overpayment 
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Trending Sources
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. In 2021, a U.S.
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These are the compliance issues providers should be preparing for, post-PHE
Healthcare IT News - Telehealth
JUNE 8, 2022
While it is important to carefully consider the most effective methods of providing care and the intended purpose behind various reimbursement, privacy, and fraud and abuse regulations, it is also clear that healthcare delivery has always and continues to evolve, and the regulatory framework needs to do the same. PTs, OTs, and SLPs).
Will CMS’s Proposed Rule on “Identified Overpayments” Increase Reverse FCA Cases?
Healthcare Law Today
JANUARY 2, 2023
As written, the proposed rule would remove the existing “reasonable diligence” standard for identification of overpayments, and add the “knowing” and “knowingly” FCA definition. And, a provider is required to refund overpayments it is obliged to refund within 60 days of such identified overpayment.
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Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme
The Health Law Firm Blog
APRIL 15, 2024
Board Certified by The Florida Bar in Health Law On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. By: George F. Indest III, J.D., The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts.
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Florida Man Agrees to Plead Guilty in $110 Million Telemedicine Medicare Fraud Scheme
The Health Law Firm Blog
MARCH 25, 2024
Board Certified by The Florida Bar in Health Law On February 16, 2024, a Parkland, Florida, man agreed to plead guilty to organizing a Medicare fraud scheme worth $110 million. By: George F. Indest III, J.D., The federal prosecution is taking place in the U.S. District Court for the District of Massachusetts.
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Doctor Indicted in $1.3 Million Medicare Fraud Kickback Case Seeks Reinstatement of Medicare Billing Privileges
The Health Law Firm Blog
JUNE 10, 2023
million Medicare fraud scheme asked a New Jersey court to eliminate a bail condition. Indest III, J.D., Board Certified by The Florida Bar in Health Law On November 2, 2021, a doctor and his wife who had been indicted for their roles in a $1.3 The doctor argued that the [.]
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Doctor Indicted in $1.3 Million Medicare Fraud Kickback Case Seeks Reinstatement of Medicare Billing Privileges
The Health Law Firm Blog
MARCH 16, 2022
million Medicare fraud scheme asked a New Jersey court to eliminate a bail condition. Indest III, J.D., Board Certified by The Florida Bar in Health Law On November 2, 2021, a doctor and his wife who had been indicted for their roles in a $1.3 The doctor argued that the.
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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
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. 405.986) or “reliable evidence” of fraud or “similar fault” (as defined in 42 C.F.R. Parts 417, 422, 423, 455, and 460.
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Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
FEBRUARY 23, 2024
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]
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Centene Agrees to Pay $19 Million to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
MARCH 14, 2024
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]
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Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
FEBRUARY 1, 2024
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]
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Centene Will Pay $19 Million to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
NOVEMBER 29, 2022
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.].
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Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations
The Health Law Firm Blog
OCTOBER 14, 2022
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.].
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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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Centene Agrees to Pay $19 Million to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
DECEMBER 19, 2022
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.].
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Centene Will Pay $19 Million Settlement to Washington State For Medicaid Fraud Allegations
The Health Law Firm Blog
NOVEMBER 7, 2022
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.].
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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. 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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18 Former NBA Players Indicted For Alleged $4 Million Health Care Fraud Scheme
The Health Law Firm Blog
FEBRUARY 10, 2023
Board Certified by The Florida Bar in Health Law On October 7, 2021, 18 former NBA players were charged in New York federal court for an alleged health insurance fraud scheme to rip off the league's benefit plan, according to an indictment filed in the Southern District [.] Indest III, J.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. These regulations are designed to ensure accurate claims, prevent fraud, and promote proper reimbursement for services rendered to patients.
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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. This means payers must rely on post-payment reviews and audits to identify those errors, overpayments, and fraudulent claims.
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Steps to Take If You Receive an OIG Subpoena from the U.S. Department of Health and Human Services
The Health Law Firm Blog
JANUARY 8, 2024
This agency investigates allegations of fraud, waste, and abuse of Medicare, Medicaid, and other federally funded healthcare programs. [.] Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG).
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Centene to Pay Washington State $19 Million to Resolve Medicaid Fraud Allegations
The Health Law Firm Blog
JANUARY 8, 2024
Board Certified by The Florida Bar in Health Law On August 24, 2022, managed healthcare company, Centene Corporation, agreed to pay $19 million to the State of Washington to settle fraud allegations. Indest III, J.D., Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]
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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
The government’s primary civil tool for addressing healthcare fraud is the FCA. The risk categories are described as follows: Highest Risk—Exclusion: Parties that the OIG determines present the highest risk of fraud will be excluded from Federal healthcare programs to protect those programs and their beneficiaries.
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The $8.3 Million Dollar Audit: How to Prevent Overpayments with Hospice Benefits
Healthicity
APRIL 12, 2022
The OIG’s Annual Workplan for 2022 includes the continuous auditing and monitoring of items and services.
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OIG Revises Self-Disclosure Protocol
Florida Health Care Law Firm
DECEMBER 2, 2021
On November 8, 2021, The Department of Health & Human Services (HHS), Office of Inspector General (OIG) released a revised and renamed Provider Self-Disclosure Protocol (SDP), now known as the “Health Care Fraud Self Disclosure “protocol. The OIG recognized that there are benefits to disclose potential fraud.
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The Power of a Quality Review: Your Best Defense Against OIG Audits
Healthcare IT Today
FEBRUARY 2, 2023
It has given every indication that it intends to investigate fraud, waste, and abuse more robustly in the foreseeable future. The Justice Department has joined the fraud case against one large national insurer. The New York Times claimed eight of the 10 largest Medicare Advantage insurers had padded their bills.
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18 Former NBA Players Indicted For Alleged $4 Million Health Care Fraud Scheme
The Health Law Firm Blog
MAY 6, 2024
Board Certified by The Florida Bar in Health Law On October 7, 2021, 18 former NBA players were charged in New York federal court for an alleged health insurance fraud scheme to rip off the league's benefit plan, according to an indictment filed in the Southern District [.] Indest III, J.D.,
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Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
Innovaare Compliance
MARCH 24, 2024
The Importance of Payment Integrity Payment integrity is crucial for health plans to control costs, reduce fraud, waste, and abuse (FWA), and ensure the accuracy of healthcare payments. The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1
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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.
Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
Innovaare Compliance
MARCH 24, 2024
The Importance of Payment Integrity Payment integrity is crucial for health plans to control costs, reduce fraud, waste, and abuse (FWA), and ensure the accuracy of healthcare payments. The Centers for Medicare & Medicaid Services (CMS) reported that in the fiscal year 2020, they recovered $3.1
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Steps to Take If You Receive an OIG Subpoena from the U.S. Department of Health and Human Services
The Health Law Firm Blog
OCTOBER 14, 2022
This agency investigates allegations of fraud, waste, and abuse of Medicare, Medicaid, and other federally funded healthcare programs. [.]. Department of Health and Human Services (HHS) issues investigative subpoenas through the Office of the Inspector General (OIG).
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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. 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.
Part 3: Audit Documentation to Avoid Potential Appeal Consequences
AIHC
APRIL 5, 2022
Due to the huge volume of claims payers receive to process, deny and pay, they have implemented various methods to track providers to detect potential waste, fraud and/or abuse. If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back.
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Hot off the Press! The OIG Revises its Self-Disclosure Protocol for the First Time in Several Years
Health Law RX
NOVEMBER 9, 2021
For the first time since 2013, on November 8, 2021, the Department of Health and Human Services Office of Inspector General (“OIG”) updated its Health Care Fraud Self-Disclosure Protocol (“SDP”). The likelihood that a self-discloser would be required to pay a damages multiplier greater than 1.5
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The Importance of a Corporate Integrity Agreement
Compliancy Group
FEBRUARY 29, 2024
Office of Inspector General (OIG) can invoke civil or criminal prosecution or licensure or other penalties, fines, exclusions from federal programs like Medicare, or revocation of billing privileges. 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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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?
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Department of Justice (DOJ) Evaluation of Corporate Compliance Programs
Compliancy Group
FEBRUARY 2, 2024
In the case of healthcare fraud or other forms of noncompliance, the organization at fault could enter a corporate integrity agreement (CIA) with the Office of the Inspector General (OIG). Other outcomes include deferred prosecution under certain conditions, penalties, and continued oversight.
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OIG Issues Highly Anticipated Industry Segment-Specific Compliance Program Guidance for Nursing Facilities
Hall Render
NOVEMBER 25, 2024
Quality of Care and Quality of Life OIG identified that beyond the Requirements of Participation for Long Term Care Facilities in 42 CFR 483 , the failure to provide quality care and promote quality of life poses a risk of fraud and abuse for nursing facilities.
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Introduction to Telebehavioral Health
AIHC
SEPTEMBER 5, 2023
Medicare covers many telebehavioral and telemental health services including audio-only services. Most private insurers and Medicaid cover telebehavioral health care, but check for reimbursement restrictions and obtain professional coding and billing guidance to avoid overpayment situations.
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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. Fraud, waste, & abuse. These improper payments may be overpayments or underpayments and do not necessarily represent expenses that should not have occurred. Jeremy.Booth@c…. Seema Verma.
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Post-Acute Compliance Program Update: OIG Proposes Amendments to Exclusion Rules
Hall Render
DECEMBER 11, 2024
The section currently requires OIG to take into account access of beneficiaries to physician services for which payment may be made under Medicare, Medicaid or other federal health care programs in determining whether to impose an exclusion.
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Fundamentals of a Healthcare Internal Business System Audit
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. Corrective action includes refunding overpayments revealed during the audit. Independence of the audit organization is a key component of a third-party audit.
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