Overpayment

"They Owe You" Does Not Always Mean You Can Withhold

by Bennett Epstein | Foley & Lardner LLP on 5/14/2013

It is common for employees to separate from employment while still owing money to their employer. Such indebtedness can be generally attributed to a variety of causes, which can be broken down into three categories...more

Absent a Contract With the Provider, HMOs Are Not Liable for Unpaid Services

by Michael Klein | Sedgwick LLP on 5/10/2013

On April 19, 2013, the Texas Supreme Court handed down its opinion in Christus Health Gulf Coast, et al. v. Aetna, Inc. et al. The court’s ruling put an end to the so-called “double pay” theory of liability by downstream...more

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

by Robert Mazer | Ober|Kaler on 5/2/2013

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

Updated Self-Disclosure Protocol Clarifies Disclosure Process and Obligations

by Brian P. Dunphy, Karen S. Lovitch, Stephanie Willis | Mintz Levin - Health Law on 4/23/2013

Individuals and entities subject to the Civil Monetary Penalty Law (CMP) have received clarification regarding the process for disclosing and resolving potentially unlawful conduct involving the federal health care programs...more

HHS Office of Inspector General Issues Updated Self-Disclosure Protocol

by Ropes & Gray LLP on 4/19/2013

On April 17, 2013, the Office of Inspector General of the Department of Health and Human Services (“OIG”) released an Updated Provider Self-Disclosure Protocol (“SDP”). The Updated SDP replaces OIG’s original Provider...more

OIG Issues Updated Self-Disclosure Protocol

by Tom Crane, Nili Yolin | Mintz Levin - Health Law on 4/18/2013

The Department of Health and Human Services Office of Inspector General (“OIG”) has published an updated Provider Self-Disclosure Protocol (the “Updated SDP”) that offers health care providers guidance on how to disclose...more

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

by Womble Carlyle Sandridge & Rice, PLLC on 4/17/2013

Recovery Audit Contractors (“RACs”) and other Centers for Medicare and Medicaid Services (CMS) contractors are charged with identifying overpayments made by Medicare to healthcare providers. However, with the increase in RAC...more

Illinois Office of the Inspector General Self-Disclosure Protocol for Reporting Medicaid Overpayment

by Nicholas Lynn | Duane Morris LLP on 4/8/2013

The Illinois Department of Healthcare and Family Services ("Department"), Office of Inspector General ("OIG"), has now issued an Informational Notice and Voluntary Provider Self-Disclosure Protocol ("Protocol") providing...more

Hospitals: Audits And Compliance

by Michael Volkov on 4/2/2013

Hospitals are under intense scrutiny. The federal government knows that one sure way to reduce healthcare costs is to get hospitals to lower their costs. Hospitals feel the pinch given the need to generate revenue but know...more

OIG Recommends Increased CMS Enforcement of SNF Standards

by Holly Barker, Kathleen McDermott | Morgan Lewis on 3/22/2013

Amid alleged failures of skilled nursing facilities to meet care and discharge planning requirements, OIG identifies substantial payment errors....more

Second Circuit Holds That Insurers May Recover Overpayments of Benefits Under ERISA

by Julie Kim | Sedgwick LLP on 3/20/2013

On March 13, the Second Circuit issued a significant opinion interpreting key provisions of the Employee Retirement Income Security Act (“ERISA”). In Thurber v. Aetna Life Ins. Co., Case No. 12-370-cv, 2013 WL 950704 (2d...more

GAO Report Finds that CMS Overpaid Medicare Advantage Plans in 2010, 2011 and 2012

by King & Spalding on 3/14/2013

On March 4, 2013, the GAO released a report titled, Substantial Excess Payments Underscore Need for CMS to Improve Accuracy of Risk Score Adjustments, in which the GAO concluded that CMS overpaid Medicare Advantage plans (MA)...more

IRS Issues New Correction Procedures for Retirement Plans

by King & Spalding on 3/1/2013

The IRS recently released new Employee Plans Compliance Resolution System (EPCRS) procedures. The new EPCRS procedures update procedures that were last issued in 2008 (the “2008 EPCRS”). Like the 2008 procedures, the new...more

OIG Reports that Millions of Medicaid Overpayments Remain Uncollected

by King & Spalding on 2/28/2013

On February 19, 2013, the OIG published a report detailing the collection status of Medicaid overpayments. The Secretary of HHS requires CMS to collect overpayments, defined as “the amount paid by a Medicaid agency to a...more

Deferred Prosecution Agreements: How an Effective Compliance Program Can Help You Plan for the Unpredictable

by John S. Linehan, Gina L. Simms | Ober|Kaler on 2/27/2013

During the past several years, prosecutors have increasingly used Deferred Prosecution Agreements (DPAs) against corporations in enforcing white collar criminal statutes. DPAs have enabled companies to avoid the costs and...more

Annual Report Shows Meteoric Rise in RAC Activity

by Ameena Ashfaq, B. Scott McBride | BakerHostetler on 2/27/2013

On February 5, 2013, CMS issued its mandatory Recovery Audit Contractor (RAC or Recovery Auditor) program annual report, detailing overpayments, underpayments, RAC performance and savings to the Medicare program. According to...more

The ERISA Litigation Newsletter - February 2013

by Anthony Cacace, Stacey Cerrone, Page W. Griffin, Jacklina Len, Kara L. Lincoln, Brian S. Neulander | Proskauer Rose LLP on 2/19/2013

In This Issue: - Editor's Overview - View from Proskauer: Are Your Conversations Privileged under ERISA? - Rulings, Filings, and Settlements of Interest ...more

CMS Publishes Annual Update On Recovery Audit Activity, Says Program Returned Nearly $490 Million to Medicare Trust Fund in 2011

by King & Spalding on 2/13/2013

On February 5, 2013, CMS sent Congress a report summarizing developments related to its Medicare recovery audit program for fiscal year (FY) 2011. According to the report (titled Recovery Auditing in the Medicare and...more

Payment Matters: No Judicial Review of Contractor’s Finding of a High Payment Error Rate, a Condition for Extrapolation

by Mark A. Stanley | Ober|Kaler on 2/11/2013

Before a Medicare contractor can use extrapolation to determine an overpayment amount, the Medicare statute requires that it must make a finding that there is a sustained or high level of payment error or that documented...more

Court Orders Employee To Pay $112,792.70 “Overpayment” Back To WSIB

by Adrian Miedema | Dentons on 2/7/2013

The Workplace Safety and Insurance Board has won a court order requiring an employee to pay back a $112,792.70 “overpayment” to the WSIB....more

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

by King & Spalding on 1/31/2013

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 Concludes in Nationwide Review of Drug That Herceptin Has Often Been Overbilled

by King & Spalding on 1/30/2013

The HHS OIG has conducted a nationwide audit of the use and reimbursement of Herceptin (also known as trastuzumab), a Medicare-covered drug used to treat metastatic breast cancer, and has concluded in three audits released in...more

Notable Healthcare Provisions Passed In The American Taxpayer Relief Act Of 2012

by Janice Anderson, Ryan McAteer, Matthew Murer, Harry Sporidis, Steven Stranne | Polsinelli on 1/30/2013

In This E-Alert: - Notable ATRA Provisions - Medicare Extensions - Other Health Provisions - Other Health Extensions - Excerpt from Notable ATRA Provisions: Medicare Physician Payment Update...more

Supreme Court Opinion in Sebelius v. Auburn Regional Medical Center Rejects a Challenge by Hospitals to Medicare's SSI Fraction...

by Stuart M. Gerson, Robert Wanerman | Epstein Becker & Green, P.C. on 1/25/2013

A unanimous Supreme Court has issued its opinion in Sebelius v. Auburn Regional Medical Center, No. 11-1231 (Jan. 22, 2013), rejecting a challenge by hospitals to Medicare's Supplemental Security Income ("SSI") fraction...more

Health Reform + Related Health Policy News Update - January 16, 2013

by Colleen M. Faddick, Bruce A. Johnson, Matthew Murer, Alan K. Parver | Polsinelli on 1/18/2013

In This Issue: - Fiscal Cliff Deal Lengthens Medicare Overpayment Recovery Period - Cutting Medicaid Provider Tax May Shift Costs to States, CRS Finds - MedPAC Finalizes Payment Recommendations, GAO Solicits...more

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