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.
Fraud Overpayment Overpayments 
Fraud Indicators and Red Flags
AIHC
FEBRUARY 17, 2025
When Audit Managers Knowingly Skew Audit Results Written by Carl J Byron , CCS, CHA, CIFHA, CMDP, CPC, CRAS, ICDCTCM/PCS, OHCC and CPT/03 USAR FA (Ret) Fraud cannot be eliminated. No system is completely fraud-proof, as any system can be bypassed or manipulated. on fraud detection and prevention in healthcare.
Fraud 
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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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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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What Are THE 3 Major Things Addressed in the HIPAA Law?
HIPAA Journal
MARCH 30, 2022
Had the level of abuse and fraud in the healthcare industry been allowed to continue, tens of billions of dollars would have been lost to unscrupulous actors. the Transactions and Code Sets Rule) and address abuse and fraud in the health care industry to reduce costs to health insurance providers. 7 Billion Lost Each Year to Fraud.
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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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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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Healthcare Professionals: Do You Know How to Prepare For, and Respond To, a Medicaid Audit Request?
The Health Law Firm
AUGUST 18, 2022
Unfortunately, the unfortunate truth is that Florida has become synonymous with healthcare fraud. As a result, auditing and subsequent overpayment demands are some very real possibilities. Indest III, J.D.,
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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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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
405.986) or “reliable evidence” of fraud or “similar fault” (as defined in 42 C.F.R. 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. 3729(b)(1)(A) of the False Claims Act (“FCA”). See Proposed Rule at 79559.
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Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program
Healthcare Law Blog
FEBRUARY 3, 2023
In addition, each MMCO must develop a fraud, waste and abuse prevention plan and submit it to OMIG within 90 days of the effective date of the new rules or upon signing a new contract with the New York State Department of Health to begin participation as an MMCO.
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New York State OMIG Makes Regulatory Modifications to Compliance Program Requirements
Health Law Advisor
AUGUST 25, 2023
Social Services Law § 363-d) codified in New York State law federal requirements and OMIG policies require Medicaid providers who have received an overpayment to report, return, and explain the overpayment by making a disclosure to OMIG within sixty (60) days of identifying the overpayment. Lines of Communication.
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What You Need to Know About Preparing and Responding to an Initial Medicaid Audit Request
The Health Law Firm
JULY 24, 2017
The unfortunate truth is that Florida has become synonymous with health care fraud. As a result, auditing and subsequent overpayment demands are very real possibilities. Indest III, J.D.,
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Preparing and Responding to an Initial Medicaid Audit Request
The Health Law Firm
JULY 17, 2015
The unfortunate truth is that Florida has become synonymous with health care fraud. As a result, auditing and subsequent overpayment demands are very real possibilities. Florida health care providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country.
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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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Responding to an Initial Medicaid Audit Request
The Health Law Firm
JULY 17, 2012
The unfortunate truth is that Florida has become synonymous with healthcare fraud. As a result, auditing and subsequent overpayment demands are some very real possibilities. Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country.
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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 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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Treatment Center Plead Guilty to Anti-kickback Statute Violations Involving Alcohol and Drug Addiction Treatment Centers
Health Law Blog
MAY 22, 2018
Substance Abuse Treatment Center Fraud Scheme Results in Guilty Plea. The Department of Justice recently announced the guilty plea of two individual alcohol and substance abuse treatment center owners for their participation in what DOJ labeled a “multi-million dollar health care fraud and money laundering scheme.”
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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 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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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. 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. 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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Clinical Trial Payments: Optimizing the Path Forward for Site Payments
HIT Consultant
JANUARY 9, 2024
Varying levels of economic development and legal systems lead to potential fraud and currency control complications as well. They can reduce the burden on clinical and financial staff for payments, disputes, reporting and reconciliations, all while minimizing site and study overall costs and overpayments.
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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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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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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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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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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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Pennsylvania Man Excluded from All Federal Healthcare Programs for 22 Years
Healthcare Compliance Blog
JUNE 9, 2022
In March of 2022, in a related matter, the man pleaded guilty to Healthcare Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the US Department of Health and Human Services between 2016 and 2020. He is awaiting sentencing on those charges.
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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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. Ensure Ongoing Compliance.
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Navigating CMS UPIC Audits: A Guide for Healthcare Organizations
Compliancy Group
FEBRUARY 7, 2024
CMS UPIC audits are designed to identify and prevent fraud, waste, and abuse within Medicare and Medicaid, ensuring that federal funds are used appropriately and that the services billed for are actually provided and are medically necessary. Given their significant impact, healthcare organizations must take UPIC audits seriously.
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SNF Billing Compliance Made Simple
Medisys Compliance
NOVEMBER 26, 2024
These regulations are designed to ensure accurate claims, prevent fraud, and promote proper reimbursement for services rendered to patients. Common Issues Impacting SNF Billing Compliance Improper Payments: Errors in coding or documentation can lead to overpayments or denials.
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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. billion in healthcare fraud judgments and settlements. billion in healthcare fraud judgments and settlements.
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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. At $1,000 per code, these errors pointed to a possible overpayment of $64,000 for the identified members.
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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. billion in healthcare fraud judgments and settlements. billion in healthcare fraud judgments and settlements.
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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. In addition, CMS education and outreach focuses on preventing, detecting, and reporting Medicare fraud and abuse. Fraud – Billing for supplies or services that were not given or provided to the patient.
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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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). The corporation might still face penalties, which could be reduced if they show good faith in identifying and remedying the offense.
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