On June 27, 2023, CMS hosted a Special Open Door Forum regarding its Review Choice Demonstration program for Inpatient Rehabilitation Facility Services (IRFs). CMS has stated that the Medicare IRF benefit continues to...more
This month, OIG updated its work plan to include a new Inpatient Rehabilitation Facility (IRF) Nationwide Audit. In explaining the new workstream, OIG cited high IRF error rates in other reviews and plans to determine whether...more
Last week, DOJ and HHS-OIG published its annual report regarding the Healthcare Fraud and Abuse Control (HFAC) Program (the Report). The Report summarizes the enforcement activity of DOJ and HHS and states that during Fiscal...more
7/29/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
FBI ,
Food and Drug Administration (FDA) ,
Fraud and Abuse ,
Healthcare Fraud ,
Medicare ,
OIG ,
State False Claims Acts ,
Trusts
In December 2021, OIG issued its Semiannual Report to Congress (SAR) covering OIG’s activities for the reporting period of April 1, 2021 through September 30, 2021, as well as the entire Fiscal Year (FY) 2021 (October 1, 2020...more
On June 21, 2021, OIG released a report titled “Medicare Lacks Consistent Oversight of Cybersecurity for Networked Medical Devices in Hospitals” (OEI-01-20-00220) (the OIG Report). OIG determined that CMS’s accreditation...more
In its November 2020 Work Plan update, OIG announced it will begin auditing short stay inpatient hospital claims under the Two Midnight Rule, and when appropriate, recommend overpayment collections. OIG does not specify the...more
On September 22, 2020, CMS announced it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. The RSNAT Prior Authorization Model assesses whether...more
On June 22, 2020, CMS issued a press release calling for a renewed national commitment to value-based payment models for healthcare providers rather than fee-for-service models. The proclamation came as CMS also released...more
On November 8, 2019, the Department of Justice (DOJ) announced a settlement with a New York hospital for $12.3 million in connection with alleged improper overlapping and concurrent urology surgeries performed by one...more
On June 17, 2019, CMS announced a voluntary settlement program for Inpatient Rehabilitation Facility (IRF) appeals pending at the Medicare Administrative Contractor (MAC), the Qualified Independent Contractor, the Office of...more
On August 3, 2018, the U.S. District Court for the Western District of Texas denied a challenge by Superior Home Health Services (Superior Home Health) to a Medicare contractor’s use of extrapolation to determine that the...more
On April 24, 2018, the Centers for Medicare & Medicaid Services (CMS) released the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS) Proposed Rule (CMS-1694-P). Among other changes, CMS proposes eliminating...more
The Department of Health and Human Services (HHS) Departmental Appeals Board (DAB) has requested suggestions for Medicare Appeals Council (Council) decisions that should be designated as precedential. The Council provides...more
Last week, HHS OIG released a report finding that Medicare inappropriately paid acute-care hospitals for outpatient services provided to beneficiaries who were inpatients of other facilities, such as long-term care hospitals,...more
On August 14, 2017, CMS announced an expansion of a Targeted Probe and Educate (TPE) review strategy for Medicare Administrative Contractors (MAC) reviews. Many providers were familiar with Probe and Educate reviews in...more
On June 16, 2017, the Department of Justice announced that Genesis Healthcare paid $53.6 million to resolve six False Claims Act whistleblower lawsuits filed by seven of Genesis’ former employees. The lawsuits alleged that...more
Although the Two Midnight Rule became effective on October 1, 2013, CMS had not updated manual guidance to incorporate the Two Midnight Rule until recently. The CMS updated the Medicare Benefit Policy Manual earlier this...more
In a status report filed on March 6, 2017, HHS revised projections regarding the Medicare appeals backlog, which make it unable to meet a court-imposed deadline to eliminate the backlog by 2020. The status report was filed in...more
On February 8, 2017, the United States District Court for the District of Connecticut declined to fully dismiss allegations filed by a class of Medicare patients against HHS in Alexander et al. v. Cochran (formerly Bagnall et...more
Although the Two Midnight Rule was effective October 1, 2013, until recently, CMS had not updated the Medicare Benefit Policy Manual (MBPM) to incorporate the Two Midnight Rule and its revisions to prior admission...more
On October 14, 2016, CMS issued its Final Rule for the new physician payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA replaced the Medicare Sustainable Growth Rate (SGR) with a new...more
10/25/2016
/ Alternative Payment Models (APM) ,
Centers for Medicare & Medicaid Services (CMS) ,
EHR ,
Final Rules ,
Medicare ,
Medicare Access and CHIP Reauthorization (MACRA) ,
Medicare Part B ,
MIPS ,
Payment Systems ,
Physician Payments ,
Physicians ,
PQRS ,
Quality Payment Program (QPP) ,
Sustainable Growth Rate (SGR) ,
Value-Based Payments