Fraud Centers for Medicare & Medicaid Services

Fraud is the making of false representations or engaging in deceptive behavior in order to unlawfully secure financial or personal gain. 
News & Analysis as of

False Claim Act: 2013 Year in Review

Last year continued the trend of robust False Claims Act (FCA) enforcement by the U.S. Department of Justice (DOJ) and proliferating qui tam lawsuits brought by whistleblowers on behalf of the United States. In 2012, DOJ...more

Health Care Fraud and Abuse Alert: What CMS’s New Billing Requirement For “Incident To” Services Means For Medicare Providers.

In the final Medicare Physician Fee Schedule for 2014 (“2014 PFS”), CMS implemented a new condition of payment for “incident to” services that has significant fraud and abuse implications for any Medicare provider who relies...more

Health Care Reform Implementation Update - September 24, 2013

With a week until a potential government shutdown and a week until open enrollment begins, the Affordable Care Act (ACA) is in the limelight. On September 20, the House voted for a continuing resolution that funds the...more

Medicare Enrollment Moratoria: Implications for Service Expansion and Certain Transactions

One of the provisions of the Affordable Care Act provided CMS with the authority to impose a temporary enrollment moratorium for a particular type of provider or supplier if determined to be necessary to combat fraud and...more

Health Care Reform Implementation Update - August 12, 2013

The House Energy and Commerce Committee voted unanimously on legislation that would repeal the sustainable growth rate (SGR) formula that has historically led to annual decreases in physician payments that are fixed at the...more

CMS Adopts New “2 Midnights” Presumption For Inpatient Hospital Admissions

On August 2, 2013, the Centers for Medicare and Medicaid Services (CMS) issued an advance copy of its final rulemaking that adopts a new approach to evaluating the medical necessity of inpatient hospital admissions. ...more

CMS Imposes Six-Month Moratoria on New Enrollments of Home Health Agencies and Ambulance Suppliers in Three Fraud “Hot Spots”

Last week, CMS announced temporary moratoria on the enrollment of new home health providers and ambulance suppliers in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) in three fraud “hot spots.”...more

Increased Availability of Health Care Data Means More Oversight and More Litigation

The increasing availability of health care claims and payment data may portend the future of government and private health care enforcement and litigation. ...more

PRIME Act: New Legislation to Curb Health Care Fraud

The United States Senate and House of Representatives recently introduced bipartisan legislation designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs. The legislation, entitled “Preventing and...more

Health Reform + Related Health Policy News - May 2013

In This Issue: - Top News ..Tavenner Wins Senate Confirmation to Head CMS ..US Charges 89 in Nationwide Medicare Fraud Crackdown - State News ..Vermont Becomes Fourth State to Allow Physician-Assisted...more

CMS Proposes Increased Rewards for Reporting Fraud and Abuse

The Centers for Medicare and Medicaid Services (CMS) recently published a proposed rule modifying certain provisions in their Incentive Reward Program (IRP) to sweeten the incentives for reporting sanctionable conduct....more

CMS Proposes Additional Incentives to Reduce Medicare Fraud Including Increase to Reward for Reporting Fraud

On April 24, 2013, CMS issued a proposed rule that would further incentivize Medicare beneficiaries and other individuals to report suspected Medicare fraud under the Medicare Incentive Reward Program. CMS is proposing to...more

White Collar Watch - April 2013

In This Issue: - Third Circuit Panel Liberalizes “Protected Activity” Immunity for Employees Claiming Whistleblower Status - Doing Time: A Requirement for White Collar Crime? - Casting a Smaller Net:...more

New Metropolitan Areas Could Affect Medicare Payment, Regulations

The U.S. Office of Management and Budget recently announced new Metropolitan Areas based on revised standards and 2010 census data. If adopted by Medicare, which they typically are, these changes would affect many aspects of...more

CMS Focuses on Fraud Associated with Increased Use of Electronic Health Records

Acting CMS Administrator, Marilyn Tavenner, recently reaffirmed the agency’s concern that the increased use of electronic health records (“EHRs”) has contributed to increases in fraudulent billing practices by providers. At a...more

GAO Report Concludes Medicare Remains High-Risk Federal Program Due to Failure to Lower Rate of Improper Payments

On February 27, 2013, the Government Accountability Office (GAO) released its High-Risk Update for Medicare and Medicaid, stating that “CMS has not met GAO’s criteria to have the Medicare program removed from the High-Risk...more

Hospitals And Fraud Enforcement

The HHS Office of Inspector General has targeted hospitals for fraud enforcement. It is one of the OIG’s most important initiatives because of the impact it could have on reducing health care costs....more

OIG Recommends that CMS Recoup More Than $100 Million in Overpayments for Incarcerated and Unlawfully Present Beneficiaries

CMS made more than $100 million in improper payments to providers for healthcare services on behalf of incarcerated and unlawfully present individuals between 2009 and 2011, according to a pair of reports issued on January...more

OIG Report Calls for More Fraud and Abuse Investigations of Medicare Advantage Plans

The HHS OIG has released a report recommending that CMS grant the Medicare Drug Integrity Contractor (MEDIC) wider latitude in pursuing potential fraud and abuse by Medicare Advantage plans. The report found that the MEDIC,...more

Health Law Update — January 10, 2013

In This Issue: - Healthcare Provisions in the American Taxpayer Relief Act - the Good, the Bad and the Ugly - American Taxpayer Relief Act Amends Overpayment Recovery Time Limits - OIG Advisory Opinion Sheds...more

Private Health Insurance Efforts To Fight Fraud

Healthcare fraudsters do not discriminate between private and public health insurance. Fraudsters use similar schemes to defraud Medicare and Medicaid and private insurance companies. ...more

Plugging The Leak: Tackling The Problem Of Healthcare Fraud

The Justice Department and the Department of Health and Human Services have made healthcare fraud a number one priority – it is another example of the synergy of politics and enforcement. Congress spends more money on...more

Birmingham Medical News: 2012 Health Care Year In Preview

The health care events of 2012 can be properly divided into "Before" and "After": Before the Supreme Court ruling on the Affordable Care Act and President Obama's re-election and After. Before these two events, the viability...more

Who is Committing Healthcare Fraud?

The financial recoveries for healthcare fraud are staggering. The Justice Department and Health and Human Services (Office of Inspector General (“OIG”) and Centers for Medicare and Medicaid Services (“CMS”)) regularly...more

Physician Payment Sunshine Act: Challenge for Companies, Tool for Enforcers

Pharmaceutical companies, medical device manufacturers, and biotech companies are gearing up for the January 1, 2013 deadline set by the Centers for Medicare and Medicaid Services (“CMS”) for companies to begin collecting...more

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