News & Analysis as of

CMS Charges $13 Million Late Payment Fee on $1 Million Medicaid Overpayment

To add insult to injury, the overpayments were inadvertent—the result of electronic coding errors on about 900 Medicaid claims. On top of that, Mt. Sinai itself didn’t make the errors. They were made by two hospitals in the...more

Overpayments to Skilled Nursing Facilities on the Rise

Nearly $2.5 billion dollars in overpayments were made to Skilled Nursing Facilities (“SNFs”) as a result of billing errors last year. The billing error rate for SNFs jumped to 7.7 percent, virtually doubling in 2013....more

CMS Announces Final Regulatory Changes to Medicare Advantage and Part D

- CMS issues final Medicare Advantage and Part D regulatory changes after a controversial proposed rule was announced earlier this year. - New requirements for the reporting and return of Medicare Advantage and Part D...more

Quantifying and addressing improper payments for Medicare evaluation and management services

A review of Medicare Part B claims for evaluation and management (E/M) services conducted by the Office of the Inspector General (OIG) has found that the program paid $6.7 billion in improper payments in 2010. This figure...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

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

OIG Proposes Rule to Expand Civil Monetary Penalties and Solicit Comments on Penalty for Failure to Report and Return Overpayments...

Department of Health and Human Services, Office of Inspector General’s (OIG) proposed rule expands the use of civil monetary penalties and solicits comments on the penalty for failure to report and return overpayments. ...more

Recent OIG Report Underscores Need for Home Health Agencies and Physicians to Comply With Medicare’s Face-to-Face Documentation...

Medicare overpaid the home health industry $2 billion between January 2011 and December 2012, according to a recent report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG). The OIG’s...more

Medicare’s 60-Day Proposed Refund Rule Imposes Significant Liability on Providers

As part of the Affordable Care Act, Congress outlined the process for providers to return Medicare and Medicaid overpayments. In 2012, CMS proposed the 60-day Refund Rule, as it is commonly known, requiring Medicare providers...more

Proposed Overpayment Reporting Requirements for MA and Part D Programs May Increase False Claims Act Liability

The Centers for Medicare & Medicaid Services continues to take an expansive view of the overpayment refund requirement, which in turn can give rise to False Claims Act liability for Medicare Advantage Organizations and Part D...more

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

CMS Issues Refunds For Collections Made On Incorrectly Identified Incarcerated Beneficiary Overpayments

Medicare does not cover supplies or services for persons who are incarcerated at the time the services are rendered. However, Medicare had purportedly paid providers in error for many such claims and sought to recover those...more

CMS Reinstates Policy for Enrollment Denials Related to Unpaid Medicare Overpayments

The saga related to CMS’ policy to deny enrollments based on a history of unpaid Medicare debts continues. We first reported on the proposed regulations and corresponding policy announcement, via Transmittal 469, expanding...more

A Review of CMS' Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present...

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present). In this post, Sheppard Mullin examines the...more

OIG Finds That Medicare Could Save Millions by Strengthening Billing Requirements for Canceled Surgeries

On August 6, 2013, OIG released a report with its findings that in a sampling of 100 hospital inpatient claims involving short-stay, canceled elective surgery admissions, 80 did not meet Medicare’s requirement that the...more

CMS Temporarily Rescinds Implementation of Enrollment Denials Related to Unpaid Medicare Overpayments

In the June 12, 2013 Payment Matters article “Enrollment Rules Continue To Provide Expanded Bases For Enforcement,” reference was made to CMS’ publication of Transmittal 469 to the Medicare Program Integrity Manual....more

CMS's Use of Contractors to Determine "Sustained or High Level of Payment Errors" Upheld

In a decision handed down on July 23, 2013, the United States Court of Appeals for the D.C. Circuit upheld the use by CMS of outside contractors to determine whether a home health agency’s reimbursement claims had exhibited a...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

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

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

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

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

Recent Changes Impact Appeal of Medicare Denials and Reimbursement Strategies

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

OIG Recommends Increased CMS Enforcement of SNF Standards

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

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

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

OIG Reports that Millions of Medicaid Overpayments Remain Uncollected

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

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