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. This is the reality for a medical company in Minnesota.

Overpayments 52

Overpayments Overpayment Fraud Governance 52

The Health Law Firm

OCTOBER 9, 2013

According to a letter from the University of Miami Hospital’s Chief Financial Officer (CFO), the hospital is contesting the Inspector General’s method for calculating the amount of the alleged overpayment.

US Department of Health and Human Services 40

US Department of Health and Human Services Medicare Medicare Overpayments 40

AIHC

SEPTEMBER 30, 2024

First, although most of the diagnosis codes that EmblemHealth submitted were supported in the medical records and therefore validated 860 of the 1,222 sampled enrollees’ HCCs, the remaining 362 HCCs were not validated and resulted in overpayments. The OIG made the following recommendations to Humana: Refund to the Federal Government the $6.8

Overpayment 52

Overpayment Overpayments Compliance Medicare 52

Healthcare Compliance Blog

MARCH 16, 2022

Erskine stated, “Nursing home facilities provide important services to our elderly; however, those facilities must uphold the trust placed in them by billing the government only for reasonable and necessary services. Periodically audit to ensure that skilled rehabilitation services being provided to residents are reasonable and necessary.

Nursing Homes 59

Nursing Homes Nurses Overpayment Overpayments 59

Health Law Advisor

AUGUST 25, 2023

In July 2022, the New York State Office of the Medicaid Inspector General (“OMIG”) proposed extensive modifications to the regulatory requirements governing compliance programs for entities receiving “significant” Medicaid revenue (increased by these regulations from a threshold of $500,000 to $1 million).

Compliance 52

Compliance Overpayment Overpayments Compliance Officers 52

AIHC

FEBRUARY 17, 2025

There are also self-reporting mechanisms in place to report overpayments on the OIG website ( Self-Disclosure ) and Self-Referral Disclosure for voluntary self-reporting of overpayments on the Centers for Medicare and Medicaid Services (CMS) website. The list of terms and definitions used throughout are below for reference.

Fraud 52

Fraud Compliance Overpayment Overpayments 52

Healthcare Law Blog

FEBRUARY 3, 2023

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] New Subpart 521-1: Compliance Programs The adopted regulations represent substantial changes to 18 N.Y.C.R.R.

Medicaid 52

Medicaid Medicaid Compliance Overpayment 52

YouCompli

FEBRUARY 22, 2023

Allegedly, the facility also failed to fully reimburse the government for its receipt of these outlier payments after it became aware of the issue. The government alleged these increased charges resulted in the greater number of outlier payments. Return illegitimate reimbursement and overpayments quickly.

Compliance 52

Compliance US Department of Health and Human Services Overpayment Overpayments 52

The Health Law Firm

FEBRUARY 20, 2018

million to settle a whistle blower lawsuit alleging its pharmacies caused federal health programs to overpay for prescription drugs by not telling the government about discounted prices. Indest III, J.D., Board Certified by The Florida Bar in Health Law On December 22, 2017, Kmart Corporation agreed to pay $32.3

Overpayments 40

Overpayments Overpayment Medicaid Medicaid 40

Florida Health Care Law Firm

DECEMBER 2, 2021

As described on the OIG website, “Self-disclosures give persons the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.”. Any overpayment retained after this period may create liability under the Civil Monetary Penalties Law and the False Claims Act.

Overpayment 40

Overpayment Overpayments Fraud Medicare 40

Health Law Blog

MAY 22, 2018

The government had accused the two owners of paying illegal kickbacks/bribes to “sober homes” in exchange for the referral of the sober homes’ insured residents to treatment program. If the allegations made by the government are to be believed, the treatment center is an illustration of exactly what intentional fraud looks like.

Fraud 52

Fraud Overpayment Overpayments Licensing 52

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 Overpayment Overpayments 52

Health Law RX

NOVEMBER 9, 2021

The updated SDP makes several important revisions and clarifications that directly impact providers and suppliers who seek to self-disclose potential violations of healthcare fraud statutes to the government. The likelihood that a self-discloser would be required to pay a damages multiplier greater than 1.5

Fraud 52

Fraud Overpayment Overpayments Governance 52

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. million (net) and $4.7 billion from 2023 through 2032, including extrapolation effects.

Overpayment 52

Overpayment Overpayments Medicare Medicare 52

HIPAA Journal

MARCH 30, 2022

However, when HIPAA was passed, the standards governing health care data, patients´ rights, and the flow of information were still several years away. It was only when the provisions of a companion bill ( HR.3103 It was not until 2002 that the Privacy Rule was published, and 2003 that the Security Rule was published.

HIPAA 136

HIPAA Fraud Health Insurance Health Care Reform 136

Hall Render

AUGUST 1, 2024

Background The FCA allows private individuals (relators) to bring qui tam lawsuits for fraudulent claims resulting in federal overpayments. This ruling is expected to have significant and lasting effects on FCA cases and the imposition of treble damages. The AKS prohibits financial inducements for referrals in federal health programs.

Overpayment 40

Overpayment Overpayments Governance 40

Hall Render

AUGUST 1, 2024

Background The FCA allows private individuals (relators) to bring qui tam lawsuits for fraudulent claims resulting in federal overpayments. This ruling is expected to have significant and lasting effects on FCA cases and the imposition of treble damages. The AKS prohibits financial inducements for referrals in federal health programs.

Overpayment 40

Overpayment Overpayments Governance 40

Medisys Compliance

NOVEMBER 26, 2024

SNF billing compliance refers to the adherence to federal and state regulations governing billing processes for skilled nursing facilities. Common Issues Impacting SNF Billing Compliance Improper Payments: Errors in coding or documentation can lead to overpayments or denials. What is SNF Billing Compliance?

Compliance 52

Compliance Medical Billing Outsourcing Medicare Medicare 52

Med-Net Compliance

OCTOBER 21, 2022

The government’s primary civil tool for addressing healthcare fraud is the FCA. Most of these cases are resolved through settlement agreements in which the government alleges fraudulent conduct and the settling parties do not admit liability.

Fraud 59

Fraud Compliance Medicare Medicare 59

YouCompli

SEPTEMBER 27, 2023

Enforcement agencies like to “follow the money,” so to speak, and they often find it in medical claims submitted to government payors such as Medicare and Medicaid.  She also claimed the hospital failed to reimburse payors for overpayment stemming from these improperly coded claims. The hospital ultimately settled and agreed to pay $3.3

Compliance 52

Compliance Overpayment Overpayments Medicare 52

C&M Health Law

DECEMBER 18, 2023

OIG specifically references the United States Sentencing Commission’s Guidelines that require that an entity’s “governing authority shall be knowledgeable about the content and operation of the compliance and ethics effectiveness of the compliance and ethics program.”

Compliance 52

Compliance Compliance Officers Governance Overpayment 52

Healthcare IT Today

MAY 5, 2023

The surge in genetic testing claims comes with a rise in fraud, waste and abuse across government and commercial payers. Common schemes include: Code stacking. This occurs when multiple CPT codes are used to delineate different phases in the genetic testing process—a process often rife with error.

Fraud 67

Fraud Medicare Medicare Overpayment 67

The Health Law Firm Blog

AUGUST 23, 2022

Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals. By George F. Indest III, J.D., Board Certified by The Florida Bar in Health Law On June 15, 2022, the U.S. This came in a ruling that limits regulators’ power to control what the program pays for certain [.].

Medicare 52

Medicare Medicare Hospitals Governance 52

Health Law RX

JANUARY 30, 2024

A failure to maintain an effective compliance program may become particularly problematic for companies with business transactions on the horizon as the government increasingly incentivizes business professionals to give compliance a seat at the deal table. Ensure Ongoing Compliance.

Compliance 52

Compliance Due Diligence Fraud Governance 52

YouCompli

OCTOBER 26, 2022

The net of it is this: Our Compliance Department performed a compliance audit related to sleep studies that resulted in a significant payback to the federal government that could have been avoided if monitoring was being performed by the Sleep Center Clinical leadership. That’s a 41% error rate with an extrapolated overpayment of?$269

Compliance 52

Compliance Compliance Officers Overpayment Overpayments 52

AIHC

OCTOBER 23, 2024

Defined Criteria” are standards identified in advance and approved for use in a specific audit, generally set by government rules, regulations or government agencies, such as CMS or pre-approved by the governing board of your organization. Corrective action includes refunding overpayments revealed during the audit.

Compliance 52

Compliance Overpayment Overpayments Medicaid 52

AIHC

MARCH 28, 2022

Government Accountability Office (GAO), improper payments have been estimated to total almost $1.7 trillion government-wide from fiscal years 2003 through 2019. Auditing and denying claims after the claims have been paid is “big money” for the government. According to the U.S.

Medicare 52

Medicare Medicare Compliance Governance 52

AIHC

APRIL 5, 2022

Audit Coding, Billing and Documentation for Accuracy Insurance carriers and government contractors have the authority to review any claims at any time. If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back.

Fraud 52

Fraud Medicare Medicare Compliance 52

Innovaare Compliance

MARCH 24, 2024

Inovaare transforms complex compliance processes by designing configurable AI-driven automation solutions so healthcare organizations can collect real-time data across internal and external departments, creating one compliance management system.

Fraud 52

Fraud Compliance Health Insurance Medicaid 52

Healthcare Law Blog

FEBRUARY 9, 2024

Sherman himself had submitted disclosure logs to the OIG), Sherman alleges that it failed to adequately report the arrangements it had with Neonatology Associates or any other private physician groups, or return any alleged overpayments.

Hospitals 52

Hospitals Compliance Officers Compliance Overpayment 52

YouCompli

NOVEMBER 1, 2023

As a result, the department now has to refund several thousand dollars in overpayments and implement a corrective action plan. In tackling the countless regulatory and operational issues for these diverse organization types, he has developed a deep understanding of the business of healthcare and the regulations governing the industry.

Compliance 52

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

YouCompli

SEPTEMBER 13, 2023

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. Mitigating fraud, waste, and abuse (FWA) is taking on a new urgency for healthcare compliance professionals.

US Department of Health and Human Services 52

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

The Health Law Firm Blog

NOVEMBER 18, 2023

Supreme Court said the federal government improperly cut more than $1 billion a year in Medicare reimbursements to hospitals. By George F. Indest III, J.D., Board Certified by The Florida Bar in Health Law On June 15, 2022, the U.S. This came in a ruling that limits regulators’ power to control what the program pays for certain [.]

Medicare 40

Medicare Medicare Hospitals Governance 40

Hall Render

DECEMBER 11, 2024

The Proposed Rule would revise the section governing exclusions under section 1128(b)(14) of the Act based on an individual’s default on a health education loan or scholarship obligation.

Compliance 40

Compliance Licensing Nurses Medicaid 40

Innovaare Compliance

MARCH 24, 2024

Inovaare transforms complex compliance processes by designing configurable AI-driven automation solutions so healthcare organizations can collect real-time data across internal and external departments, creating one compliance management system.

Fraud 52

Fraud Health Insurance Medicaid Medicaid 52

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. ” The health plan required patients to have an X-ray first to prove a CT scan was needed.

Medicare 106

Medicare Medicare Governance Overpayment 106

AIHC

SEPTEMBER 5, 2023

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. This requirement can sometimes apply to specific types of professionals when located in law or regulations governing their profession.

COVID-19 59

COVID-19 Telemedicine Informed Consent Compliance 59