News & Analysis as of

Audit Trails: Pitfalls of Electronic Medical Records, Part III

I do not profess to be an expert in the complexities of metadata in an electronic medical record (EMR). In simple terms, it is analogous to leaving footprints in the sand; although these do not wash away with high tide. In...more

Got A Complaint About RAC Audits? Get In Line

Criticism of the RAC (recovery audit contractor) program is becoming a national pastime. Needless to say, hospitals hated the program from the very beginning. And little wonder. The program pays private contractors a...more

China’s National Auditing Office Notes Compliance Concerns with Sponsorship of Academic Conferences in the Healthcare Sector

In China, it is common industry practice for pharmaceutical companies to sponsor academic conferences. As long as such events are aimed at enhancing the practice of medicine and patient welfare, the practice has been allowed....more

Health Law Alert: HIPAA Enforcement on the Rise, as OCR Audit Program Moves Forward

A recent settlement from New York—involving the largest fine levied to date in the history of HIPAA enforcement, a staggering $4.8 million imposed on two public hospitals—should remind health care providers, health plans and...more

Proposed Expansion of OIG’s Exclusion Authority

In May, the Office of Inspector General of the Department of Health and Human Services (OIG) proposed a new rule (Rule) that would implement changes included in the ACA. The Rule would expand OIG’s authority to exclude...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

Health Care in 2014: A Brave New World

With the completion of the enrollment phase of the Affordable Care Act (ACA), health care in the United States has entered a new era that will be characterized by extensive changes and challenges for both providers 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

Victory in House of Representatives for Improvements to WOSB Federal Contract Program

On May 7, 2014, the Office of Federal Contract Compliance Programs (OFCCP) issued Directive 2014-01, instituting a five-year moratorium on the OFCCP enforcement over TRICARE subcontractors. The moratorium applies to health...more

TRICARE: DOL Announces 5-Year Moratorium on Affirmative Action Compliance Audits

Previous Health Law Updates reported on the efforts of the U.S. Department of Labor (DOL) to apply equal employment opportunity mandates to providers that subcontract to provide healthcare services for TRICARE beneficiaries....more

Health Headlines: Also in the News - May 2014

OIG Reports Jurisdiction H Contractors Made $3.3 Million in Overpayments for Outpatient Drugs – According to a recent OIG report, the Medicare Contractors for Jurisdiction H overpaid providers approximately $3.3...more

OCR Announces the Results from it's Pilot Audit and it's Plans For Next Year

The Office of Civil Rights Audit Pilot Program has come to an end with 115 audits, primarily in person, having been completed. The Pilot Program had multiple revelations in privacy, some of which were probably, not so...more

HIPAA Impaired Providers and the ER - What Happens When Your Employee Becomes Your Patient?

I was speaking this week at IAHIMA’s Annual Conference on the issues relating to HIPAA audits and recent updates from OCR and ONC. As part of my program we typically solicit questions prior to the presentation, most of which...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

Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015. Medicare Recovery Audit Contractors...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

Third Circuit Holds Judicial Review of Extrapolated Overpayment Determinations is Precluded

On February 12, 2014, the U.S. Court of Appeals for the Third Circuit held that Federal courts do not have jurisdiction to review HHS’s determination of a “sustained or high level of payment error,” one of two possible...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

Possible Hospital RAC Audits in 2014: Pow! Right in the Kisser!

Whew…it’s a new year. While I thoroughly enjoyed 2013, I am excited and hopeful for 2014. Work is so busy that it seems like I’ve barely had time to breathe this January….that’s a good thing, right? Hey, anyone see me on...more

OIG Releases Report on EHR Fraud Controls

On December 11, 2013, the HHS Office of Inspector General (OIG) released a report examining provider use of certain fraud controls in certified electronic health record (EHR) technology. OIG’s survey of 864 hospitals found...more

Extrapolated Medicaid Audits Continue: Be Proactive! (Or Move to West Virginia)

Extrapolated audits are no fun, unless you work for a recovery audit contractor (RAC). You get a Tentative Notice of Overpayment (TNO) that says the auditor reviewed 100 dates of service (DOS), found an overpayment of...more

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