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.
Doctors and Debt: Why Short Visits Create Long-Term Challenges
HIT Consultant
APRIL 7, 2025
More doctorsare leaving private practice, more consolidation into massive hospital systems, and less personalized care for patients. Doctors deliver care with no guarantee of compensation, while insurers and middlemen profit without taking on any risk. The True Cost of Healthcare People say the U.S. The result?
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Healthcare Compliance Experts: This Webinar Workshop Could Save Your Hospital Millions of Dollars in Overpayments
Healthicity
MARCH 4, 2022
The OIG continues to perform focused audits on hospital claims using billing data from thousands of hospitals.
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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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OIG Findings on Overpayments at Critical Access Hospitals
Healthicity
NOVEMBER 29, 2022
Health and Human Services Office of Inspector General (OIG) recently issued a report concluding that Medicare and patients combined overpaid more than a million dollars for the same professional services provided at critical access hospitals (CAH). Who Bills for Professional Services?
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Breaking Down the OIG’s First Industry-Specific Guidance
YouCompli
FEBRUARY 4, 2025
Even if an entity makes an isolated billing error, that entity still has an obligation to repay the overpayment to avoid False Claims Act liability. This includes conducting regular reviews to ensure billing and coding practices are current and accurate, as well as performing regular internal billing and coding audits.
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Weekly Roundup – February 25, 2023
Healthcare IT Today
FEBRUARY 25, 2023
Read more… Retrieving Billions in Medicare Overpayments. Improper payments for Medicare are estimated to exceed $43 billion per year, and determining overpayments in open-ended value-based Medicare Advantage plans poses a problem. 5G has significant transformative potential for healthcare, both within and outside the hospital.
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Medicare Overpayment for Outpatient Medication — A Supreme Court Ruling in Context
NEJM
JANUARY 13, 2023
A 2022 Supreme Court ruling raises questions about the 340B program’s outsized effect on the health care system’s structure and on the role of hospitals in providing care to underserved populations.
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Updated Compliance Program Guidance for Nursing Facilities
Compliancy Group
FEBRUARY 12, 2025
Nursing facilities should: Conduct Regular Reviews and Audits: Regular reviews and audits of billing and coding practices help ensure compliance with Medicare and Medicaid program rules and prevent overpayments or fraudulent claims.
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Avoiding Red Flags: Finding the Right Productivity Balance
Healthcare IT Today
NOVEMBER 22, 2022
The payer could also recoup the overpayments from future visits. . According to WebPT’s 2022 State of Rehab Therapy report , “Educational institutions and inpatient hospitals top the patient volume charts, with each of its providers seeing approximately 20 patients per day.” . About John Wallace.
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Medicare Compliance Review of West Florida Hospital in Pensacola
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 Audit Claims University of Miami Hospital Owes Government $3.7 Million
The Health Law Firm
OCTOBER 9, 2013
Board Certified by The Florida Bar in Health Law The University of Miami Hospital allegedly owes Medicare $3.7 This is according to an audit report of the hospital’s billing practices that found the hospital allegedly overbilled the health care program in 2009 and 2010. Indest III, J.D.,
2023 Benchmark Report: Healthy Bottom Lines are Reliant on Cross-Functional Team Collaboration, Technology, & AI Investments
Healthcare IT Today
JANUARY 17, 2024
Insights are also from auditing professional and hospital claims totaling more than $5 billion and denials from commercial and government payors exceeding $150 billion. Those are the high-level findings of MDaudit’s 2023 Benchmark Report on the trends, challenges, and opportunities encountered by U.S.
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Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough
McBrayer Law Blog
NOVEMBER 18, 2020
Posted In Code Enforcement , Hospitals It may seem like hair-splitting, but including the wrong diagnostic codes for malnutrition on hospital inpatient claims – using codes for severe malnutrition in place of other forms of malnutrition – is a costly mistake.
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Fixing Medicare Advantage Payments
Healthcare IT Today
FEBRUARY 22, 2023
CMS requires chart reviews to catch overpayments. A key measure of quality used by CMS is whether the patient carries through with a follow-up visit after a hospitalization, or continues to seek treatment for a condition such as cancer. They’re valuable for many reasons.
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Finding Success Amid Complexity: 3 Payer Strategies for Better Risk Adjustment Results
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.
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Posthospital SNF Care in Indiana Generally Met Medicare Level-of-Care Requirements
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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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
We note, however, that an MA plan may elect to offer, as a Medicare benefit, coverage for post-hospital skilled nursing facility care without a prior qualifying hospital stay that is required under traditional Medicare. If finalized, the amendments would have aligned the Medicare standard with the standard for liability under 31 U.S.C.
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Weekly Health Care Real Estate Briefing: Hospital Bond Issues Down 57% | CMS Increases Payments to SNFs | New Podcast on Timeshare Arrangements | MN Hospital Deploys 24 Robots
Hall Render
AUGUST 4, 2023
In its latest capital markets update, H2C noted that July nonprofit hospital bond issuance was down 57% year-over-year and down 52% year-to-date (compared to January through June 2022). Essentia Health (Duluth, MN) held a ribbon-cutting ceremony to celebrate the opening of its $900 million replacement hospital in Duluth.
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Compliance Risks Associated with Outlier Payments
YouCompli
FEBRUARY 22, 2023
It is “prospective” because hospitals and other providers know ahead of time what they will be reimbursed. The CCR is determined by a hospital’s cost report that is reconciled with the local Medicare contractor. If they were not, the hospital must return the funds. This means reimbursement is not typically based on charges.
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ChristianaCare Settlement Drives New Legal Theory in False Claims Act Litigation: Hospitals Take Note When Providing Clinical Services to Their Private Physician Groups
Healthcare Law Blog
FEBRUARY 9, 2024
Following the resolution of this case, hospitals are encouraged to revisit their arrangements with private physician groups to ensure that proper safeguards are in place to mitigate FCA risk. Hospitals may also want audit rights to ensure that it has the ability to monitor billing compliance by private physicians on a regular basis.
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Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program
Healthcare Law Blog
FEBRUARY 3, 2023
New Subpart 521-3: Self-Disclosure Program New Subpart 521-3 implements the long-standing requirement that all enrolled Medicaid providers report, return and explain overpayments received from the Medicaid program through OMIG’s Self-Disclosure Program.
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Non-Monetary Compensation to Physicians: New Limits for 2024 and Chance to Review 2023
Hall Render
DECEMBER 27, 2023
Under the federal Stark Law, hospitals, physician groups, labs and other provider entities may provide non-monetary ( i.e. , non-cash or cash equivalent) compensation to physicians up to an aggregate amount of $507 for calendar year 2024. and the entity may not bill for such services unless an exception is met.
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Supreme Court Rules Against HHS in Hospital Medicare Reimbursement Case
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. 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 [.].
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52 Supreme Court Rules Against HHS in Hospital Medicare Reimbursement Case
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. 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 [.]
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Increasing Enforcement of Modifier Codes
YouCompli
SEPTEMBER 27, 2023
In a different case involving a hospital, a whistleblower alleged she had alerted hospital leadership of modifier misuse. In a complaint filed with the court, the whistleblower alleged the hospital had been improperly adding these modifiers to claims between 70 and 95 percent of the time.
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Healthcare Compliance is Everyone’s Business: Legal, Internal Audit, Human Resources and Quality
YouCompli
MAY 17, 2023
Physician contracting is an area of considerable risk for most hospitals and health systems. We further identified overpayments and developed a plan to refund. Acute care hospitals are required to participate in the Hospital Inpatient Quality Reporting (IQR) program. Let me give you an example. At times, things go wrong.
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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
CMS has agreed to suspend statutory obligations to report or return overpayments while the OIG negotiates a settlement with providers who are following the SDP. The likelihood that a self-discloser would be required to pay a damages multiplier greater than 1.5
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Enhancing Payment Integrity in Healthcare through Pre-Payment Reviews
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.
The Importance of a Corporate Integrity Agreement
Compliancy Group
FEBRUARY 29, 2024
When a hospital, doctor’s office, or other healthcare organization is guilty of a regulatory or compliance violation , the U.S. By examining the purpose and regulatory mechanisms of these agreements, we can understand their role in ensuring compliance, promoting ethical conduct, and ensuring patient and employee safety.
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2023 Non-Monetary Compensation to Physicians (and Chance to Review 2022)
Hall Render
DECEMBER 6, 2022
Under the federal Stark Law, hospitals, physician groups, labs and other provider entities may provide non-monetary (i.e., The dollar limit for “medical staff incidental benefits” provided by a hospital to a member of its medical staff (e.g., and the entity may not bill for such services, unless an exception is met.
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AI-First Health Plan Operations
Healthcare IT Today
AUGUST 11, 2023
Accuracy is also an issue, with many payers spending resources recovering overpayments. AI-Improved Stakeholder Experiences Healthcare lags retail, banking, finance, airline, hospitality, and virtually every other industry in terms of intelligent services, streamlined transactions, and consumer satisfaction.
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Discover what’s new for CMS Program Audit ODAG Protocol in 2022
Innovaare Compliance
JUNE 28, 2022
This causes claims to providers to be paid incorrectly, which results in enrollees being overcharged for their coinsurance or delayed refund of overpayments. .
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Health Care Real Estate Briefing: HHS Extends Public Health Emergency | SNF Staffing Shortages Still on the Rise | Record Amount of Real Estate to Hit the Market This Year
Hall Render
APRIL 18, 2022
reduction in funds to account for overpayments by CMS in previous years per Modern Healthcare. Banner Health is in the process of buying 40 to 50 acres in Scottsdale, AZ for a new hospital per Phoenix Business Journal. The Public Health Emergency has been in effect since January 27, 2020. in fiscal year 2023.
Navigating CMS UPIC Audits: A Guide for Healthcare Organizations
Compliancy Group
FEBRUARY 7, 2024
The outcome of these audits can range from repayment of overpayments to criminal prosecution in cases of fraud. Healthcare Providers and Suppliers This includes physicians, hospitals, home health agencies, durable medical equipment suppliers, and other entities that bill Medicare and Medicaid.
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Avoiding “Gotcha” Moments in Compliance
YouCompli
NOVEMBER 1, 2023
As a result, the department now has to refund several thousand dollars in overpayments and implement a corrective action plan. 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.
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Improving Patient Care With a “Prevent, Detect, Report” Strategy
YouCompli
SEPTEMBER 13, 2023
Moreover, compliance professionals should report activities such as upcoding or unbundling in a timely manner so overpayments can be promptly returned. This could include how to submit a hotline report on the HHS-OIG website.
Introduction to Telebehavioral Health
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. Substance use disorders impact a significant number of individuals, families, and communities.
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Compliance is Everybody’s Business: Clinical, Revenue Cycle, IT, Sales and Marketing
YouCompli
DECEMBER 14, 2022
Here, any overpayment from a governmental payer source must be returned within 60 days of its identification. Those issues can help with early identification of localized and more systemic issues. Everyone in our discipline is likely aware of the possibility of “reverse false claims” liability.
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Part 3: Audit Documentation to Avoid Potential Appeal Consequences
AIHC
APRIL 5, 2022
If the payer, such as Medicare, performs an extrapolation, reducing each overpayment dollar through appeal can mean thousands less to pay back. If the claim is coded POS 11 for the office, reimbursement can be higher than if the same service was performed at the hospital by the provider.
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Part 2: Understanding How Payers Deny Claims
AIHC
MARCH 28, 2022
CERT errors are listed by the following categories: The Recovery Audit Program Most hospitals and clinics are familiar with the “RAC” or Recovery Audit Contractor program – now referred to as the “Recovery Audit Program” by CMS.
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52 OIG Issues Highly Anticipated Industry Segment-Specific Compliance Program Guidance for Nursing Facilities
Hall Render
NOVEMBER 25, 2024
The Nursing Facility ICPG provides that, even if an entity makes an isolated billing error, the entity still has an obligation to repay the overpayment to the government to avoid False Claims Act liability, as explained in the GCPG.
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Digital health is ready for its second act. Will it deliver on its promise to empower patients and providers?
Redox
APRIL 29, 2019
We recognize that it’s no longer enough for a hospital to get a patient well enough to go home. One great hope of digital health technology is that it will empower the patient and finally make this possible. They want to be able to email their doctors, schedule their own appointments, and access past test results from their phone.
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These are the compliance issues providers should be preparing for, post-PHE
Healthcare IT News - Telehealth
JUNE 8, 2022
But even now, hospitals and health systems should be preparing proactively to meet the regulatory demands of a post-PHE future. Additionally, any reimbursement resulting from these claims could be considered an overpayment. But sooner or later, that provision of the Public Health Service Act will draw to a close.
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