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.,

Overpayments 98

Overpayments Overpayment Medicare Medicare 98

Healthcare IT Today

FEBRUARY 17, 2023

Amid swirling accusations that Medicare Advantage Organizations (MAOs) are overbilling the U.S. government and calls for better oversight , the Centers for Medicare & Medicaid Services announced in early February that it would investigate overbilling by those plans. How can such overpayments be uncovered?

Overpayment 89

Overpayment Overpayments COVID-19 Medicare 89

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.

Overpayment 122

Overpayment Overpayments Medicare Medicare 122

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.

Overpayments 162

Overpayments Overpayment Medicare Medicare 162

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.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

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

Medicare 105

Medicare Medicare Overpayments Overpayment 105

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.

Overpayments 52

Overpayments Overpayment Medicare Medicare 52

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

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%.

Overpayments 52

Overpayments Overpayment Compliance Medicare 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.

Medicare 87

Medicare Medicare Overpayments Overpayment 87

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

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.

Overpayments 154

Overpayments Overpayment Medicare Medicare 154

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.

Medicare 118

Medicare Medicare Overpayments Overpayment 118

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

Overpayment 69

Overpayment Overpayments Medicare Medicare 69

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

Medicare 98

Medicare Medicare Overpayments Overpayment 98

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

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.

Overpayments 40

Overpayments Overpayment Medicare Medicare 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.

Overpayments 52

Overpayments Overpayment Medicaid Medicaid 52

Healthcare IT News - Telehealth

JUNE 8, 2022

Additionally, several telehealth flexibilities (that generally expand Medicare coverage for telehealth services) have been extended 151 days (about five months) beyond the termination of the HHS PHE. If Medicare coverage requirements for telehealth services (e.g., If Medicare coverage requirements for telehealth services (e.g.,

US Department of Health and Human Services 197

US Department of Health and Human Services Compliance COVID-19 Overpayments 197

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

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.

Overpayments 92

Overpayments Overpayment Ransomware Medicare 92

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).

Overpayments 111

Overpayments Overpayment Medicare Medicare 111

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?

Overpayment 52

Overpayment Overpayments Hospitals Medicare 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.

Overpayment 51

Overpayment Overpayments Medicare Medicare 51

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.

Overpayments 126

Overpayments Overpayment Compliance Medicare 126

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 Overpayments Overpayment 52

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 Overpayments Overpayment 59

Healthicity

APRIL 12, 2022

The OIG’s Annual Workplan for 2022 includes the continuous auditing and monitoring of items and services.

Overpayment 52

Overpayment Overpayments Fraud Medicare 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.

Overpayment 40

Overpayment Medicaid Overpayments Medicaid 40

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 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.

Overpayments 52

Overpayments Overpayment Fraud Governance 52

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.

Medicare 40

Medicare Medicare Compliance Overpayments 40

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.

Overpayments 52

Overpayments Overpayment Medicare Medicare 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 Overpayments Overpayment 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.

Nursing Homes 59

Nursing Homes Nurses Overpayments Overpayment 59

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.

Overpayments 52

Overpayments Overpayment Compliance 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.

Overpayments 52

Overpayments Overpayment Medicaid Medicaid 52