News & Analysis as of

Health Care Providers May Waive Patients' Copayment Obligations, But...

In a difficult economic environment, many health care providers are actively trying to increase cash flow and reduce administrative expenses. One potential way for providers to accomplish these goals is to discount their...more

Private Health Insurance Fraud — Billions And Billions

When it comes to health insurance fraud, Carl Sagan’s obsession with the words – billions and billions — are particularly accurate. As the government’s role in health care increases, it is inevitable that fraud against...more

OIG Advisory Opinions Provide Some Helpful Guidance

In spite of a slow start, the OIG has issued a number of interesting advisory opinions to date in 2013. Here are a few of the highlights. The OIG reiterated its long-standing concern about arrangements which “carve out”...more

Pathology Lab That Cannot Demonstrate Adequate Physician Orders Suffers Medicare Loss

Much has been written regarding various Medicare policies that may cause a clinical laboratory to suffer the resulting financial consequences when a test requested by a physician is found to be not medically necessary, most...more

Federal Government Aggressively Pursuing Health Care Fraud

Proactive self-audits help providers identify potential problems - The Federal Government is using every tool available to fight health care fraud and recover overpayments from health care providers. According to the...more

OIG Publishes Audit of Outpatient Therapy Services Seeking Return of $3.1 Million in Reimbursements

In June 2013, the Department of Health and Human Services, Office of Investigator General (OIG) published a review of its audit of an outpatient therapy services provider. The OIG concluded that the outpatient therapy...more

U.S. Supreme Court Ruling: Defense of Marriage Act ("DOMA")

While the U.S. Supreme Court(the “Court”) ruled section 3 of the Defense of Marriage Act (“DOMA”) unconstitutional, that does not mean that the changes for human resources departments and employee benefits plans can be...more

2013 and 2014 under the Affordable Care Act - Updated as of May 14, 2013

This is an update on an earlier Client Advisory on this subject, with updates to reflect recently issued guidance. Employers should consider the following checklist of new requirements as the nation moves ahead with...more

Court of Appeals Rules for Government in DSH Exhausted Benefit Day Appeal

For the last several years, hospitals and the government have fought hard over where days associated with certain “dual eligible” patients should be placed in the Medicare disproportionate share hospital (DSH) calculation. At...more

New HIPAA Rules Regarding Genetic Information Affect Employers, Group Health Plans, Health Insurers and Healthcare Providers

Genetic Information Under HIPAA - While the final rule supplementing and modifying the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, Breach Reporting and Enforcement Rules—78 Fed. Reg....more

CMS Announces Proposed Rule Implementing the ACA's MLR Requirements for MA and Prescription Drug Plans

On February 15, the Centers for Medicare & Medicaid Services (CMS) released its Proposed Rule, effective calendar year (CY) 2014, implementing the Medical Loss Ratio (MLR) requirements for Medicare Advantage (MA)...more

To Waive or Not to Waive, That is the Question

A burgeoning problem is developing for out of-network healthcare providers that systemically fail to collect deductibles and coinsurance from patients. Insurance companies often seek to deny insurance coverage to subscribers...more

The SMART Act: A Bipartisan Attempt to Make the MSP Act Workable

On January 10, 2013, President Obama signed into law H.R. 1845, which includes the Strengthening Medicare and Repaying Taxpayers Act of 2011 (SMART Act). The SMART Act amends several portions of the Medicare Secondary Payer...more

Privatizing Health Insurance Companies For Anti-Fraud Enforcement

The federal government faces overwhelming challenges in trying to stem the tide of fraud in the health care system. The problem is massive, and even with the increase in resources, and adoption of new tools to fight fraud,...more

Health Reform + Related Health Policy News Update - December 19, 2012

In This Issue: - President Opposes Medical Device Tax Repeal or Replace - Senators Call for Extension of Comment Period on ACA Proposed Rules - AHA Urges U.S. District Court to Expedite Case Involving CMS' Payment...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

In Case You Were Confused, Medicare is for the Benefit of Employees, not Employers

Most employers these days know that they cannot set a mandatory retirement age for employees. This arcane practice runs directly afoul of the Age Discrimination in Employment Act (ADEA)....more

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