Health Law Advisor

FEBRUARY 2, 2023

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. The final rule codifies long-awaited regulations first proposed by CMS in 2018.

Medicare 98

Medicare Medicare Overpayment Overpayments 98

Healthcare Law Blog

AUGUST 25, 2023

On August 21, 2023, the New York State Office of the Medicaid Inspector General (OMIG) announced updates to the Medicaid overpayment self-disclosure program, which now includes an abbreviated process for reporting and explaining overpayments that are considered routine or transactional in nature and have been already voided and adjusted.

Overpayment 52

Overpayment Overpayments Medicaid Medicaid 52

Compliancy Group

FEBRUARY 12, 2025

Using the ICPG to Maintain an Effective Compliance Program The Centers for Medicare & Medicaid Services (CMS) has issued participation requirements for nursing facilities in the Medicare and Medicaid programs (Requirements of Participation or ROPs). The ICP covers the areas listed below.

Nurses 52

Nurses Compliance Medicare Medicare 52

The Health Law Firm

FEBRUARY 15, 2016

Board Certified by The Florida Bar in Health On February 11, 2016, the Centers for Medicare and Medicaid Services (CMS) published a final rule which eased requirements for health care providers to return overpayments within 60 days to avoid False Claims Act (FCA) liability. Indest III, J.D.,

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

Health Care Law Brief

JUNE 26, 2022

With this denial, the Overpayment Rule remains in full force and effect, and UnitedHealthcare, among other MA plans, must comply or potentially face False Claims Act (FCA) liability. Congress also required CMS to use the “same methodology” to calculate the costliness of insuring a beneficiary in the MA program and in FFS Medicare.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

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.

Overpayments 52

Overpayments Overpayment ACA Medicare 52

Hall Render

JANUARY 12, 2023

On December 27, 2022, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule that could potentially have a significant impact on enrollees’ obligations under the “60-day” overpayment rule. It is not until after this six-month investigation period that the 60 days to report starts to run.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

The Health Law Firm

JANUARY 30, 2020

We have gotten calls from healthcare professionals, including physicians, dentists, pharmacists, mental health counselors, and assisted living facilities (ALFs) who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results. Some providers are even forced out of business as a result.

Medicaid 40

Medicaid Medicaid Overpayments Overpayment 40

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.

Medicare 59

Medicare Medicare Overpayment Overpayments 59

Hall Render

FEBRUARY 14, 2023

billion in overpayments from MAOs for payment years 2011 through 2017. 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.

Overpayments 40

Overpayments Overpayment Medicare Medicare 40

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. The SRFs include low-income subsidy, dual eligibility (meaning eligible for Medicare and Medicaid) and disability.

Medicare 52

Medicare Medicare Overpayment Overpayments 52

Health Care Law Brief

APRIL 3, 2023

On Friday, March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies ( Rate Announcement ). 1395w-23): Medicare Advantage Organizations (MAOs) are paid a base rate by CMS. Risk Adjustment.

Medicare 52

Medicare Medicare Overpayment Overpayments 52

Innovaare Compliance

MARCH 1, 2022

The monthly premium for Medicare Part B rose 14.5%, from $148.50 By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1] By law, the Medicare Part B monthly premium must equal 25% of the estimated total Part B costs for enrollees age 65 and over. [1]

Medicare 52

Medicare Medicare Overpayment Overpayments 52

McBrayer Law Blog

NOVEMBER 18, 2020

The estimated overpayment as a result of these coding errors is a reported $1 billion. The Centers for Medicare & Medicaid Services ("CMS") also plans to implement review practices for malnutrition coding on a sample of inpatient claims.

Compliance 52

Compliance Overpayment Overpayments Medicare 52

HIT Consultant

AUGUST 22, 2022

Smart Response complements Anomaly’s planned suite of products powered by its AI claim prediction engine, including overpayment prediction, which enables payers to predict and prevent overpayments by learning from previously overpaid claims, and instant payments, which will enable providers to immediately get paid upon claim submission.

Overpayment 52

Overpayment Overpayments Medicaid Medicaid 52

Hall Render

JANUARY 10, 2025

On January 1, 2025, the Centers for Medicare and Medicaid Services’ (“CMS”) new 60-Day Rule became effective. However, under the updated rule, the obligation to report and return an overpayment begins upon identification, even if the exact amount is undetermined. The rule is codified at 42 U.S.C. 1320a-7k(d).

Overpayment 40

Overpayment Overpayments ACA Medicare 40

Healthcare Law Blog

SEPTEMBER 28, 2023

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. MAOs will be required to remit improper payments identified during RADV audits in a manner specified by CMS.

Medicare 52

Medicare Medicare Overpayments Overpayment 52

The Health Law Firm Blog

JANUARY 12, 2024

Board Certified by The Florida Bar in Health Law The nation's largest Medicaid insurer, Centene, has agreed to pay $165.6 million to Texas to resolve claims that it overcharged the state’s Medicaid program for pharmacy services. By George F. Indest III, J.D., The deal was signed on July 11, 2022, but wasn’t publicly [.]

Medicaid 52

Medicaid Medicaid Overpayments Overpayment 52

The Health Law Firm Blog

OCTOBER 18, 2022

Board Certified by The Florida Bar in Health Law The nation's largest Medicaid insurer, Centene, has agreed to pay $165.6 million to Texas to resolve claims that it overcharged the state’s Medicaid program for pharmacy services. By George F. Indest III, J.D., The deal was signed on July 11, 2022, but wasn’t publicly [.].

Medicaid 52

Medicaid Medicaid Overpayments Overpayment 52

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.

Overpayment 52

Overpayment Overpayments Fraud Governance 52

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 [.]

Fraud 52

Fraud Medicare Medicare Doctors 52

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.

Fraud 52

Fraud Medicare Medicare Doctors 52

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.

US Department of Health and Human Services 59

US Department of Health and Human Services Overpayments Overpayment Medicare 59

HIT Consultant

SEPTEMBER 27, 2024

Increasingly rigorous oversight from the Centers for Medicare & Medicaid Services (CMS) and Office of the Inspector General (OIG) are calling for better diligence, planning and administrative oversight for effective risk adjustment. billion in overpayments to MA plans with this new audit methodology over the next ten years.

Overpayment 52

Overpayment Overpayments Medicare Medicare 52

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.

Fraud 52

Fraud Medicare Medicare Telemedicine 52

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.

Fraud 52

Fraud Medicare Medicare Telemedicine 52

AIHC

SEPTEMBER 30, 2024

Medicare & the OIG are performing Risk Adjustment audits, are you? This was originally mandated by the Centers for Medicare & Medicaid Services (CMS) back in 1997 and implemented in 2004. HealthAssurance, through CVS Health, disagreed with the OIG’s audit methodology and overpayment estimation methodology.

Overpayment 52

Overpayment Overpayments Compliance Medicare 52

Healthcare IT Today

FEBRUARY 2, 2023

As proof, several health plans have been making headlines for coding errors and other issues that surfaced during audits: In just the third quarter of 2022, at least four audits have specifically targeted Medicare Advantage plans. The New York Times claimed eight of the 10 largest Medicare Advantage insurers had padded their bills.

Medicare 69

Medicare Medicare Overpayments Overpayment 69

The Health Law Firm

NOVEMBER 21, 2014

This Work Plan is the general overview of how the OIG intends to carry out its mission to make the Medicare and Medicaid programs run more smoothly and efficiently in the following year. A large part of what the OIG does is review and investigate Medicare claims for overpayment.

Overpayment 40

Overpayment Overpayments Medicare Medicare 40

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 [.].

Medicare 52

Medicare Medicare Hospitals Governance 52

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.

Fraud 52

Fraud Compliance Medicare Medicare 52

The Health Law Firm Blog

JULY 26, 2023

Board Certified by The Florida Bar in Health Law Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. By George F. Indest III, J.D.,

Medicare 52

Medicare Medicare Nurses Overpayments 52

The Health Law Firm Blog

JUNE 27, 2023

Board Certified by The Florida Bar in Health Law Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. By George F. Indest III, J.D.,

Medicare 52

Medicare Medicare Nurses Overpayments 52

The Health Law Firm Blog

JUNE 9, 2023

Board Certified by The Florida Bar in Health Law Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. By George F. Indest III, J.D.,

Medicare 52

Medicare Medicare Nurses Overpayments 52

The Health Law Firm Blog

MAY 17, 2023

Board Certified by The Florida Bar in Health Law Many healthcare professionals are unaware of the adverse long-term collateral effects of Medicare revocation or exclusion on their careers and future employment. By George F. Indest III, J.D.,

Medicare 52

Medicare Medicare Nurses Overpayments 52

The Health Law Firm

FEBRUARY 20, 2018

The department store chain withheld certain information from Medicare Part D, Medicaid and Tricare, the Department of Justice (DOJ) said. Indest III, J.D., Board Certified by The Florida Bar in Health Law On December 22, 2017, Kmart Corporation agreed to pay $32.3 The Whistle Blower False Claims Act (FCA) Suit.

Overpayment 40

Overpayment Overpayments Medicaid Medicaid 40

Med-Net Compliance

OCTOBER 21, 2022

Issue: Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. 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.

Fraud 59

Fraud Compliance Medicare Medicare 59