News & Analysis as of

Third Circuit Holds Judicial Review of Extrapolated Overpayment Determinations is Precluded

On February 12, 2014, the U.S. Court of Appeals for the Third Circuit held that Federal courts do not have jurisdiction to review HHS’s determination of a “sustained or high level of payment error,” one of two possible...more

Streamlined RAC Appeal Processes Lead To Winning Legal And Economic Outcomes

Armed with the Recovery Audit Contract (RAC) Program, the Federal government has been very successful in recouping Medicare overpayments from health care providers in recent years. During a RAC audit, program contractors...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

OIG Recommends that CMS Scrutinize Clinicians with High Cumulative Payments

Focusing on clinicians who receive high cumulative payments under Medicare Part B could be a useful means of identifying possible improper payments, according to a recent report issued by the Office of Inspector General of...more

NYS Identifies $496 Million in Medicaid Home Health Erroneous Payments

On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid...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

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

Hospitals: Audits And Compliance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

31 Results
|
View per page
Page: of 2