Lots of health care service providers find themselves in the position of needing to file a Medicare appeal. Despite the systematic nature of modern Medicare billing, wrongful denials remain common, and errors during Medicare...more
3/26/2024
/ Auditors ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Denial of Insurance Coverage ,
Health Care Providers ,
Medicare ,
Medicare Appeals ,
OMHA ,
Physician Medicare Reimbursements ,
Redeterminations ,
Reimbursements
According to the National Health Care Anti-Fraud Association, an estimated $100 billion is lost to Medicare fraud every single year in the U.S., with overtaxed law enforcement agencies relying heavily on whistleblowers to...more
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
Yesterday, the U.S. Department of Justice (DOJ) announced that it has filed charges against 36 defendants in relation to an alleged health care fraud scheme that resulted in approximately $1.2 billion in fraudulent payments....more
7/21/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Criminal Prosecution ,
Department of Justice (DOJ) ,
Enforcement Actions ,
FBI ,
Health Care Providers ,
Healthcare Fraud ,
Kickbacks ,
Medicare ,
Medicare Beneficiaries ,
Physician Medicare Reimbursements ,
Physicians ,
Telehealth ,
Telemarketing ,
Telemedicine
Targeted Probe and Educate (TPE) audits have recently become a common tool used by both law enforcement and private insurers in the Medicare program. While they focus on educating Medicare providers about proper billing...more
6/21/2022
/ Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Criminal Investigations ,
Health Care Providers ,
Healthcare Fraud ,
Medical Billing Codes ,
Medical Records ,
Medicare ,
Medicare Administrative Contractors (MAC) ,
Medicare Appeals ,
Medicare Fraud ,
Penalties ,
Physicians ,
Targeted Probe and Education (TPE) audit
For diabetic patients and the doctors who treat them, blood sugar levels are crucially important. However, the traditional method of testing one’s blood sugar with a pin-prick is undesirable for many patients, which leads to...more
The federal government has recently made clear its intention to go after healthcare providers who provide amniotic injections to certain Medicare and Medicaid recipients. Over recent years, the federal government has...more
10/26/2021
/ Anti-Kickback Statute ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Civil Investigation Demand ,
Civil Liability ,
Criminal Liability ,
Defense Strategies ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Government Investigations ,
Health Care Providers ,
Healthcare Fraud ,
Medicaid ,
Medicare ,
Physicians ,
Stark Law
Cardiovascular stress testing to diagnose patients with coronary artery disease (CAD) and other related types of conditions can be a highly-effective tool in many cases. In fact, many cardiologists routinely recommend stress...more
8/24/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
Documentation ,
False Billing ,
Health Care Providers ,
Investigations ,
Local Coverage Determinations (LCDs) ,
Medical Necessity ,
Medicare ,
Medicare Fraud ,
OIG ,
Policies and Procedures ,
Stress Tests
The Centers for Medicare and Medicaid Services (CMS) and U.S. Department of Justice (DOJ) are scrutinizing health care providers’ Medicare billings for amniotic injections. These injections are only eligible for Medicare...more
8/17/2021
/ Anti-Kickback Statute ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Civil Investigation Demand ,
Department of Justice (DOJ) ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Fraud ,
Medicare ,
Medicare Fraud
Durable medical equipment (DME) is particularly important for many Medicare beneficiaries. However, companies that manufacture and sell DME need to be careful because there are strict federal regulations outlining almost...more
7/28/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Chief Compliance Officers ,
Civil Liability ,
Compliance ,
Compliance Commitees ,
Corrective Action Plans (CAPs) ,
Criminal Liability ,
Department of Health and Human Services (HHS) ,
Disciplinary Proceedings ,
Durable Medical Equipment ,
Employee Training ,
Health Care Providers ,
Healthcare Fraud ,
Medicaid ,
Medicare ,
OIG ,
Physicians ,
Policies and Procedures ,
Standard of Conduct ,
TRICARE
Zone Program Integrity Contractors (ZPICs) are federal contractors that work under the direction of the Centers for Medicare and Medicaid Services (CMS) to uncover fraudulent billings under Medicare. ZPICs have broad...more
5/25/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Defense Strategies ,
Department of Justice (DOJ) ,
Enforcement Actions ,
False Billing ,
Health Care Providers ,
Healthcare Fraud ,
Medicare ,
Overpayment ,
Provider Payments ,
Underpayment ,
Zone Program Integrity Contractors (ZPICs)
Medicare pays billions of dollars in fraudulently billed claims each year despite the various tools the Medicare system has at its disposal. Because of this problem, the Centers for Medicare and Medicaid Services (“CMS”)...more
4/6/2021
/ Centers for Medicare & Medicaid Services (CMS) ,
Defense Strategies ,
Documentation ,
False Billing ,
Fraud and Abuse ,
Health Care Providers ,
Healthcare Fraud ,
MACs ,
Medicare ,
Physicians ,
Recovery Audit Contractors (RACs)
The Office of Inspector General is a division of the U.S. Department of Health and Human Services that is tasked with combating fraud committed against Medicare, Medicaid, and other federally funded government programs. The...more
3/10/2021
/ Clinical Laboratories ,
Compliance ,
Compliance Monitoring ,
Corrective Action Plans (CAPs) ,
Dentists ,
Department of Health and Human Services (HHS) ,
Health Care Providers ,
Healthcare Facilities ,
Healthcare Fraud ,
Hospitals ,
Internal Audit Functions ,
Medicaid ,
Medical Billing Codes ,
Medicare ,
Nursing Homes ,
OIG ,
Pharmacies ,
Physicians ,
Policies and Procedures
Most health care providers have at least a basic understanding of the Anti-Kickback Statute. This federal law prohibits providers from offering, paying, soliciting, or accepting any form of “remuneration” for patient...more
12/11/2020
/ Anti-Kickback Statute ,
Civil Liability ,
Clinical Laboratories ,
Criminal Liability ,
Criminal Penalties ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Facilities ,
Medicaid ,
Medicare ,
Medicare Part D ,
Noncompliance ,
Patient Referrals ,
Physicians ,
Policies and Procedures ,
Stark Law
Compliance is a key aspect of operating a successful pharmacy in the United States. This is true for pharmacies that bill federal healthcare benefit programs (i.e. Medicare, Medicaid, and Tricare) as well as private payors,...more
8/3/2020
/ Americans with Disabilities Act (ADA) ,
Cannabidiol (CBD) oil ,
Compliance ,
Controlled Substances Act ,
DEA ,
DSCSA ,
Federal Trade Commission (FTC) ,
GINA ,
Health Insurance ,
Medicaid ,
Medical Billing Codes ,
Medicare ,
Pharmacies ,
Pharmacist ,
Pharmacy Benefit Manager (PBM) ,
Policies and Procedures ,
Risk Mitigation ,
TRICARE