Centene to pay more than $71M to settle Medicaid overpayment cases in Illinois, Arkansas
Fierce Healthcare
SEPTEMBER 30, 2021
Centene to pay more than $71M to settle Medicaid overpayment cases in Illinois, Arkansas. Thu, 09/30/2021 - 16:43.
CMS Proposes to Amend Overpayment Rule, Remove Potential Overpayment and False Claims Act Liability for Mere Negligence
Healthcare Law Blog
DECEMBER 27, 2022
The Centers for Medicare and Medicaid Services (“CMS”) has issued a proposed rule which would amend the existing regulations for reporting and returning identified overpayments (the “Proposed Rule”). UnitedHealthcare challenged the current Overpayment Rule in litigation. [1] UnitedHealthcare Litigation. The Proposed Rule.
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What Payers Need to Know to Stay Ahead in 2025
MRO Compliance
JANUARY 16, 2025
To address these gaps, the Centers for Medicare & Medicaid Services (CMS) now mandates the use of FHIR-based APIs for data sharing. Many claims analysts feel that chasing down overpayments feels like plugging leaks in a sinking boat. This is why payers are now shifting toward pre-pay accuracy.
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The 60-Day Rule: What Healthcare Professionals Need to Know
Healthicity
MARCH 6, 2025
The 60-day rule under the Affordable Care Act is one of the most important compliance regulations for healthcare providers accepting Medicare or Medicaid payments. It requires organizations to identify, report, and return any overpayments within 60 days of discovery.
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New York Medicaid Providers Now Have Two Pathways to Self-Disclose Overpayments to the Office of the Medicaid Inspector General
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.
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CMS Issues Long-Awaited Medicare Advantage RADV Final Rule
Healthcare Law Blog
FEBRUARY 1, 2023
On January 30, 2023 , the Centers for Medicare & Medicaid Services (“CMS”) released the long-delayed final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”). case number 18-5326 , which reinstated CMS’s Overpayment Rule for MA organizations. See also Ratanasen v.
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Medicaid Providers Beware: Failure to Appeal Audit Results or Pay Medicaid Overpayments May Result in Termination of License
The Health Law Firm
FEBRUARY 27, 2013
Our firm has been consulted recently by owners of different health care entities, including assisted living facilities (ALFs), group homes, home health agencies and even medical groups that had received Medicaid overpayment demands. This resulted in a Medicaid overpayment assessment.
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Medicare Advantage Overpayments: Are You Ready for RADV Audits?
Innovaare Compliance
DECEMBER 14, 2023
Cigna allegedly submitted inaccurate patient diagnosis data to the Centers for Medicare & Medicaid Services (CMS), impacting payments received and raising serious compliance concerns. CMS’s Role and the RADV Audits Program Medicare Advantage overpayments have become alarmingly problematic in the private payer program.
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Breaking Down the OIG’s First Industry-Specific Guidance
YouCompli
FEBRUARY 4, 2025
When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, it certifies the services were provided in compliance with all applicable statutes, regulations, and rules. 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.
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The Supreme Court Denies Petition Challenging CMS’s Overpayment Rule
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. The Overpayment Rule. The Overpayment Rule, set forth at 42 U.S.C. 29844, 29921 (May 23, 2014). See UnitedHealthcare Insurance Co. 3d 173 (Sep.
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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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Updated Compliance Program Guidance for Nursing Facilities
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.
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CMS To Relax Medicare 60-Day Overpayment Rule
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.,
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CMS Proposes to Drastically Change Overpayment Refund Rule
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. In fact, claims reviews to quantify an overpayment is a time-consuming effort and the six-month period is necessary.
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Attention New York Medicaid Providers: It’s Time to Upgrade Your Compliance Program
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.
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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
Board Certified by The Florida Bar in Health Law Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are some very real possibilities. Indest III, J.D.,
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Report: Inaccurate Drug Discount Requests Reach Nearly $1B
HIT Consultant
JUNE 15, 2023
Rising Costs of Inaccurate Drug Discount Claims As the Medicaid Drug Rebate Program (MDRP), 340B Drug Pricing Program and other similar programs expand, so do the volume and cost of duplicate discounts and other inaccurate drug discount claims.
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CMS’s Final Rule on Medicare Advantage Risk Adjustment Data Validation
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. billion between 2023 and 2032 from MAOs based on both non-extrapolated and extrapolated overpayment amounts.
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CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments
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.
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Responding to an Initial Medicaid Audit Request
The Health Law Firm
JULY 17, 2012
Florida healthcare providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are some very real possibilities. By Lance O. Leider, J.D. The unfortunate truth is that Florida has become synonymous with healthcare fraud.
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Health Facility Entitled to Attorney's Fees Against AHCA in Defending Medicaid Overpayment Case
The Health Law Firm
JULY 6, 2015
FACTS: Via three Final Audit Reports dated July 10, 2013, AHCA advised the Chrysalis Center that it had overbilled the Medicaid program by $284,535.83 for community mental health services.
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Preparing and Responding to an Initial Medicaid Audit Request
The Health Law Firm
JULY 17, 2015
Florida health care providers servicing Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are very real possibilities. Facts You Should Know About the Medicaid Audit Process.
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Healthcare Professionals: You Must Challenge Overpayment Demands from Medicare and Medicaid Audits
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. Once placed on prepayment review, the payments are held up for many months.
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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
Board Certified by The Florida Bar in Health Law Health care providers in Florida who service Medicaid patients are at a higher risk for audits than anywhere else in the country. As a result, auditing and subsequent overpayment demands are very real possibilities. Indest III, J.D.,
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Centene Reaches $166 Million Settlement With Texas Over Its Medicaid Drug Pricing
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 [.]
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Centene Reaches $166 Million Settlement With Texas Over Its Medicaid Drug Pricing
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 [.].
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Are You the Target of a Medicaid Audit? Tips Health Professionals Should Be Following
The Health Law Firm Blog
NOVEMBER 18, 2023
Board Certified by The Florida Bar in Health Law The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), and Bureau of Medicaid Program Integrity is the Florida agency responsible for routine Medicaid audits The agency ensures that the Medicaid program was billed correctly for [.] Indest III, J.D.,
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Are You the Target of a Medicaid Audit? Tips Health Professionals Should Be Following
The Health Law Firm Blog
AUGUST 24, 2022
Board Certified by The Florida Bar in Health Law The Agency for Health Care Administration (AHCA), Office of Inspector General (OIG), and Bureau of Medicaid Program Integrity is the Florida agency responsible for routine Medicaid audits The agency ensures that the Medicaid program was billed correctly for [.]. Indest III, J.D.,
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Florida Attorney Says AHCA Must Put Medicaid Final Orders Online
The Health Law Firm Blog
SEPTEMBER 20, 2023
Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]
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Florida Attorney Says AHCA Must Put Medicaid Final Orders Online
The Health Law Firm Blog
AUGUST 24, 2023
Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]
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Florida Attorney Says AHCA Must Put Medicaid Final Orders Online
The Health Law Firm Blog
JULY 19, 2023
Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]
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Florida Attorney Says AHCA Must Put Medicaid Final Orders Online
The Health Law Firm Blog
JUNE 27, 2023
Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]
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Florida Attorney Says AHCA Must Put Medicaid Final Orders Online
The Health Law Firm Blog
MAY 16, 2023
Board Certified by The Florida Bar in Health Law Florida's Agency for Health Care Administration (AHCA) has come under fire for failing to make Medicaid final orders accessible to the public. Indest III, J.D., On April 11, 2023, an attorney asked a Florida appeals court to revive her suit against [.]
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New York State to Fund Bonuses for Certain Healthcare Workers as Part of State Budget
Health Care Law Brief
MAY 11, 2022
No bonus amount may be paid to any worker who has been suspended or excluded under the Medicaid program during the vesting period and at the time an employer submits a claim. Bonus amounts will be commensurate with the number of hours worked by covered workers during designated vesting periods up to a total of $3,000 per covered worker.
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New York State OMIG Makes Regulatory Modifications to Compliance Program Requirements
Health Law Advisor
AUGUST 25, 2023
It is axiomatic that New York State requires every Medicaid provider to have an “effective” compliance program. Part 521, make several important changes that will affect all Medicaid Providers’ compliance programs throughout New York State. New York Social Services Law § 363-d. The final regulations, codified at 18 N.Y.C.R.R.
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CMS’s 60-Day Rule Impacts False Claims Act Liability
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).
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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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AI Provider Anomaly Launches Tech to Predict Claims Denials with 97% Accuracy
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.
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Malnutrition Diagnosis Codes: The Compliance Danger You’re Not Taking Seriously Enough
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.
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Finding Success Amid Complexity: 3 Payer Strategies for Better Risk Adjustment Results
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.
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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. The SRFs include low-income subsidy, dual eligibility (meaning eligible for Medicare and Medicaid) and disability. See 42 U.S.C.
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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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Conducting Internal Risk Adjustment Coding Audits
AIHC
SEPTEMBER 30, 2024
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. HCC coding relies on ICD-10-CM coding to assign risk scores to patients.
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Office of Inspector General Work Plan 2015: A Provider's Overview-Part 1
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.
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