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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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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Medicaid Medicaid Compliance Overpayments 52

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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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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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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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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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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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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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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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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Overpayments Overpayment Medicare Medicare 52

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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Medicaid Medicaid Overpayments Overpayment 52

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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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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Medicaid Medicaid Overpayments Overpayment 52

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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Medicaid Medicaid Overpayments Overpayment 52

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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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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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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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 [.].

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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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Medicaid Medicaid Overpayments Overpayment 52

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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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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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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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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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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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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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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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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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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The Health Law Firm Blog

FEBRUARY 23, 2024

By George F. Indest III, J.D., 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. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]

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The Health Law Firm Blog

MARCH 14, 2024

By George F. Indest III, J.D., 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. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]

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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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The Health Law Firm Blog

FEBRUARY 1, 2024

By George F. Indest III, J.D., 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. Centene owns and operates Sunshine State Health Plan, d/b/a Sunshine Health, in Florida. In addition, [.]

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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. In this model, healthcare claims are paid upfront, and then potential errors, overpayments, or fraudulent claims are “chased down” after payment has been made.

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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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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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Florida Health Care Law Firm

DECEMBER 2, 2021

The OIG clarified that using the SDP may mitigate potential exposure under Medicare and Medicaid 60-day reporting and returning requirements for overpayments. Any overpayment retained after this period may create liability under the Civil Monetary Penalties Law and the False Claims Act.

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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.

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