News & Analysis as of

Overpayment Billing

King & Spalding

OIG Audit Finds Medicare Overpaid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation

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On August 12, 2024, OIG announced the results of an audit of payments made to hospitals for inpatient claims with the Medicare Severity Diagnosis-Related Groups (MS-DRGs) that require ninety-six hours of consecutive...more

Oberheiden P.C.

10 Keys to a Successful Pharmacy Audit Appeal

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Medicare, Medicaid, and pharmacy benefit manager (PBM) audits can result in substantial losses for pharmacies. If auditors uncover evidence—or apparent evidence—of overpayments, not only can they initiate recoupments, but...more

Fox Rothschild LLP

My Medical Practice Is Being Audited. Now What?

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Private and government payers are initiating more medical practice audits, and that trend is likely to continue. In order to successfully navigate the process, providers should prepare in advance to meet the audit challenge. ...more

Health Care Compliance Association (HCCA)

Hospital Settles FCA Case Filed by CO Over Modifiers; Make Sure People ‘Feel Heard’

Report on Medicare Compliance 30, no. 32 (September 13, 2021) - John Peter Smith (JPS) Hospital in Fort Worth, Texas, agreed to pay $3.3 million to settle false claims allegations in a case with a hot risk area, a...more

Maynard Nexsen

How to Avoid Healthcare Overpayments: Top Five Mistakes Providers Make and the Real Cost of Non-Compliance

Maynard Nexsen on

Over the last 25 years, I have assisted healthcare providers as a lawyer and as a compliance professional with handling routine overpayment matters, internal and external billing investigations, and fraud and abuse matters. ...more

Health Care Compliance Association (HCCA)

Report on Medicare Compliance Volume 29, Number 43. News Briefs: December 2020

Report on Medicare Compliance 29, no. 43 (December 7, 2020) - In a new provider compliance audit, the HHS Office of Inspector General (OIG) said The Palace at Home, a for-profit home health care agency (HHA) in Miami,...more

Akin Gump Strauss Hauer & Feld LLP

11th Circuit’s Decision in AseraCare: Important in Determining When Clinical Judgment Regarding Medical Necessity Can Result in an...

• Reasonable disagreement among clinicians, by itself, does not result in a false claim. • Clinical judgment must be objectively false to constitute an FCA violation. • A clinical judgment may only be objectively false...more

King & Spalding

District Court Dismisses Hospice False Claims Act Case Where Relator Failed to Identify False Records or Claims

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On June 26, 2019, the United States District Court for the Northern District of Ohio granted a motion to dismiss a qui tam lawsuit against HCR ManorCare Inc. and its subsidiaries, including Heartland Hospice Services, LLC...more

King & Spalding

OIG Hospital Compliance Program Audit Claims $22 Million in Extrapolated Overpayments

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A recent report issued by OIG finding an Indiana community hospital owed over $22 million in extrapolated overpayments carries some important lessons for hospitals audited under OIG’s hospital compliance program. As described...more

Hinshaw & Culbertson LLP

Medical Litigation Newsletter - December 2016

Hinshaw & Culbertson LLP on

Defending Audits Before They Happen: A Practical Guide to Documenting to Sustain A Challenge to E/M Codes - Although many believe malpractice suits to be the primary risk-management issue facing healthcare providers, an...more

Ruder Ware

Provider Self-Disclosure Decisions – Voluntary Disclosure Process

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The decision whether or not to voluntarily disclose non-compliance to the government can be very difficult. Not every case is clear. Clearly not every situation where there has been a billing error amounts to fraud or...more

McDermott Will & Emery

Program Integrity Changes to the Medicare Provider Enrollment Process

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On March 1, 2016, the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) published a proposed rule (Proposed Rule) entitled “Medicare, Medicaid, and Children’s Health Insurance...more

Holland & Knight LLP

FCA 60-Day Repayment Provision Runs from Discovery of Potential Overpayment

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The U.S. District Court for the Southern District of New York issued the first decision directly addressing when an overpayment is “identified” for purposes of starting the 60-day repayment clock under the federal False...more

Baker Donelson

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

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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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