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Healthcare Dive
JUNE 14, 2023
The figure is almost triple prior estimates of MA overpayments, highlighting the need for payment reform to avoid overtaxing the Medicare system, researchers said.
284 
Healthcare Dive
JUNE 22, 2022
The justices declined to take up the case, leaving intact a lower court ruling that backed the 2014 CMS regulation requiring swift return of overpayments.
307
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Healthcare Dive
SEPTEMBER 5, 2023
The payer, which brings in the bulk of its revenue from Medicare, is fighting back against a rule finalized earlier this year to claw back overpayments in the increasingly popular MA program.
301 
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.
98 
Modern Healthcare
JULY 28, 2022
An OIG audit outlined millions in uncollected overpayments, holes in internal accounting system
115 
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.
98 
Fierce Healthcare
JUNE 13, 2023
Legislators and policymakers have put payments to Medicare Advantage (MA) plans under the microscope, and new analysis highlights why. Legislators and policymakers have put payments to Medicare Advantage plans under the microscope, and new analysis highlights why.
120 
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.
130 
Fierce Healthcare
JULY 14, 2023
Steve Lieberman and other experts co-authored | While insurers would likely fight massive changes to the program, experts say less drastic updates could still go a long way toward lowering overpayments. When Paul Ginsburg, Ph.D.,
98 
Fierce Healthcare
OCTOBER 6, 2023
million in overpayments from Medicare Advantage in 2015 and 2016. | million in overpayments from Medicare Advantage in 2015 and 2016. A new federal audit estimates that Aetna may have received at least $25.5 A new federal audit estimates that Aetna may have received at least $25.5
94 
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”). One thing that is certain, CMS can expect further challenges to its RADV audit methodology. 3d 1, 18 n.19
105 
Healthcare Dive
SEPTEMBER 6, 2023
Favorable selection of healthier beneficiaries led to overpayments in counties with high Medicare Advantage penetration, but benchmark changes could mitigate the impact, according to a study published in Health Affairs.
157 
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.
59 
Medisys Compliance
JULY 5, 2022
What is Medicare Overpayment? An overpayment is a payment made to a provider exceeding amounts due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require CMS recover overpayments. Medicare Overpayment Collection Process.
52 
Healthcare IT Today
FEBRUARY 22, 2023
There’s widespread consensus that payments to Medicare Advantage Organizations (MAOs) are a mess. These programs, which care for more than 30 million of the nearly 64 million Medicare enrollees , operate on the cutting edge of health care and suffer serious problems in data collection and billing.
113 
Innovaare Compliance
DECEMBER 14, 2023
In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage plans, particularly in the areas of compliance and risk assessment. CMS’s Role and the RADV Audits Program Medicare Advantage overpayments have become alarmingly problematic in the private payer program.
52 
Modern Healthcare
MARCH 17, 2022
As Xavier Becerra approaches his one-year anniversary at HHS' helm, he's interested in working with Congress on Medicare Advantage overpayment issues and physician payment reform.
87 
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. This total includes $41.1
98 
Health Populi
JUNE 5, 2022
In 2006 the Medicare Part D program was implemented, covering older Americans for prescription drugs for the first time. Medicare further drove expansion of generic drug utilization, with co-pays for generics lower for Medicare enrollees than branded drugs. is that 9 in 10 medicines prescribed are generics. healthcare spending.
154 
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.
52 
YouCompli
MARCH 22, 2023
There has been significant enforcement over the last couple years relating to overpayments for UDT. According to the OIG, prior error rate testing has suggested an improper payment rate of almost 30% for Medicare. The overpayment rate for definitive drug testing for 22 or more drug classes was over 71%.
52 
Fierce Healthcare
JANUARY 2, 2024
Medicare Part D will cover certain over-the-counter products when prescribed by a clinician, and when it does, the program pays far more for these drugs, according to a
67 
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.,
40 
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.
52 
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.
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.
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. In fact, claims reviews to quantify an overpayment is a time-consuming effort and the six-month period is necessary.
40 
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.
52 
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. Read more… Fixing Medicare Advantage Payments.
88 
Healthcare IT Today
NOVEMBER 22, 2022
The number of Medicare TPEs and commercial payer take-back audits alone is skyrocketing. They also look to flag “items and services that have high national error rates and are a financial risk to Medicare.” Meanwhile, Medicare also has a Fee for Service Recovery Audit Program. Tricare and Medicare).
107 
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.
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.
59 
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.
52 
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?
52 
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.
51 
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]
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.
40 
Healthcare IT Today
JANUARY 17, 2024
External Audits Surge Among the report’s standout findings is the significant uptick in external payor audits in 2023, a result of escalating federal government efforts to address the overpayments made in the past two to three years. Moreover, extended adjudication times (29-35 days) for initial responses to claims impacted cash flows.
122 
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.
40 
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 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.
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 [.]
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.
52 
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.
52 
Healthcare Compliance Blog
MARCH 16, 2022
In a March 11, 2022, release by the Northern District of Georgia’s Office of the Department of Justice, it was reported that an investigation determined a Georgia nursing home knowingly submitted claims for unreasonable, unnecessary, and unskilled services for Medicare patients. This amount was based on the nursing home’s ability to pay.
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