News & Analysis as of

Who Audits the Auditors?

Since the advent of Medicare in 1965, hospitals have bemoaned the cost and burden of Medicare audits. The complaints increased when CMS hired private contractors for the audits. They became deafening in 2009 with the advent...more

CMS Paying Some Providers’ Medicare EHR Incentive Payment Using Incorrect Transition Factor

We have learned that CMS has paid Medicare EHR Incentive Program Payments to some eligible hospitals using an incorrect transition factor, understating total payment. CMS personnel have informed us that they are aware of this...more

Brace Yourself: The RACs Are Back

Under the controversial program private contractors audit hospitals and other Medicare providers for fraudulent and erroneous Medicare billing. Why is it controversial? Because the auditors are paid a percentage of...more

Health Headlines: Also in the News - June 2014 #4

CMS Holds Medicare Advantage and Prescription Drug Oversight and Enforcement Conference – On June 24, 2014, CMS offered an in-person program that instructed Medicare Advantage and Part D providers as to how they could...more

CMS Changes to Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015

On May 19, 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule, published in the Federal Register on May 23, 2014, that sets forth changes to requirements for Medicare Advantage (“MA”) and...more

CMS's Focus on DMEPOS Fraud and Abuse Risks Continues

The focus by the Centers for Medicare & Medicaid Services (CMS) on Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as an area rife with unnecessary utilization and a high improper payment rates...more

Emerging EHR Risks: When Documentation May Not Be Enough (or Too Much)

Today’s Electronic Health Record (EHR) technologies feature many tools that help providers practice more efficiently and allow them to spend more time caring for patients. However, the federal government recently has posted...more

CMS Identifies Key Priorities for 2014 Compliance Reviews of Qualified Health Plans in the Federally Facilitated Marketplace

At a Centers for Medicare & Medicaid Services ("CMS") teleconference titled "Compliance Reviews in the Federally-Facilitated Marketplace" ("FFM"), which was held on April 10, 2014, CMS representatives discussed the agency's...more

CMS Releases Fiscal Year 2012 Recovery Auditing Report

In a recent report on the Recovery Audit program for fiscal year (FY) 2012, CMS reports that Recovery Auditors identified $2.4 billion dollars in improper payments, including $2.3 billion in overpayments and $109.4 million in...more

CMS Posts Guidance on Two-Midnight Rule and Related Audits

On February 24, 2014, CMS posted a list of updates to its guidance on the new Two-Midnight Rule and the Probe and Educate Audits. Several of the more major updates are discussed below....more

A Calm Before the Storm: Updates on CMS Audit Activity

In February 2014, CMS made two announcements that affect future Medicare audits. First, CMS instructed RACs to stop issuing post-payment additional documentation requests (ADRs) after February 21 and instructed MACs to stop...more

CMS Announces Transition Process for RAC Contracts

On February 18, 2014, CMS announced that it is in the procurement process for the next round of Recovery Audit Contractor (RAC) program contracts and that the transition to new contracts will include a pause in RAC audits in...more

CMS Announces "Pause" in RAC Audits

On Tuesday, 2/18/14, Centers for Medicare & Medicaid Services (CMS) announced on its website that it is “pausing” the Recovery Audit Program (RA Program) in preparation for the procurement of new Recovery Audit (RA) contracts...more

CMS Proposed Rule Would Modify Risk Adjustment Data Collection, Data Validation Audits with Some Material Effects

The Centers for Medicare & Medicaid Services’ proposal for risk adjustment data collection demonstrates the agency’s continued concern that Medicare Advantage Organizations’ activities are resulting in more “intense” coding,...more

Medicaid DSH: Little-Noticed CMS Rule Interpretation Creates Serious Financial Shortfalls for Impacted Hospitals

In what may have been a largely unnoticed rule interpretation affecting hospitals that treat a high percentage of children in the Medicaid program, CMS, in January 2010, issued a response to a Frequently Asked Question (FAQ)...more

CMS Issues Additional Guidance Related to 2-Midnight Rule

Earlier this month, CMS posted three new documents related to the 2-midnight rule for inpatient admissions on its webpage for inpatient hospital reviews: new FAQs, as well as CMS directions for selecting hospital claims for...more

GAO Calls For Consistency Among Medicare Contractors Postpayment Claims Review

The U.S. Government Accountability Office (GAO) recently published the results of a study examining the effectiveness of CMS’s contractors that conduct postpayment claims reviews to identify improper payments (i.e., Medicare...more

Healthcare Regulation Update: GAO Makes Recommendations to HHS and CMS Regarding Medicare Audit Consistency

Following a detailed study of the manner by which the Centers for Medicare and Medicaid Services (“CMS”) engages in postpayment claims reviews to identify improper payments, the U.S. Government Accountability Office (“GAO”)...more

OIG and MA Plan Sponsor Settle Allegations of Altering Records Submitted During Audit

Bravo Health Pennsylvania, Inc. (Bravo), a Medicare Advantage Plan Sponsor and subsidiary of Cigna Corporation, agreed to pay $225,000 to the Government for allegedly misrepresenting or falsifying information furnished to the...more

Healthcare Regulation Update: CMS to Develop New Integrity Contractors Called “Unified Program Integrity Contractors”

The American Health Care Association (“AHCA”) has reported that the Centers for Medicare & Medicaid Services (“CMS”) will be making efforts to streamline its audit structure. Among the changes will be the development of a new...more

CMS Announces New Unified Program Integrity Contractors

CMS recently announced plans to implement a new Medicare and Medicaid program integrity contractor, Unified Program Integrity Contractors (UPICs). ...more

What Have We Learned from Audits under the Medicare EHR Incentive Program?

Through the first half of this year, the Centers for Medicare & Medicaid Services auditor has conducted numerous pre- and post-payment audits of meaningful use attestations submitted by eligible providers to the Medicare...more

2013 Healthcare Fraud and Abuse Bootcamp Webinar Series, Part V: Compliance

Bill Mathias of Ober|Kaler's Health Law Group presented on compliance as a part of the 2013 Healthcare Fraud and Abuse Bootcamp Webinar Series sponsored by the American Health Lawyers Association. This webinar...more

Tips to Prepare for a CMS Electronic Health Record Meaningful Use Audit

In an effort to improve patient care, the Centers for Medicare and Medicaid Services (“CMS”) established electronic health record (“EHR”) Incentive Programs, which provide financial incentives for the “meaningful use” of...more

Self-Audit Results Found Sufficient to Sustain False Claims Act Complaint

District Court Finds That Medical Group’s Failure to Further Investigate Audit Results May Violate Requirement to Return Overpayments - Background - Internal audits of third-party payment claims – frequently...more

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