News & Analysis as of

Audits Centers for Medicare & Medicaid Services

New Audits and Penalties on Medicaid Plans and Providers Related to Encounter Data in Value-Based Payment Models

by Epstein Becker & Green on

For value-based payments, encounter data[1] provides valuable information in much the same way that claims data does for fee-for-service arrangements. With the growing prevalence of value-based payments, especially in the...more

CMS Expanding The "Targeted Probe And Educate" Audits Nationally This Fall

by Roetzel & Andress on

The Centers for Medicare and Medicaid Services (“CMS”) announced recently that it will be expanding its medical claims review program to cover the entire country by the end of this year. The expanded program, titled “Targeted...more

OIG Work Plan – September 2017 Update

by Baker Ober Health Law on

Beginning in June 2017, the OIG began making monthly Work Plan updates. These monthly updates create some practical challenges for health care providers and compliance professionals trying to make operational and compliance...more

The Rise of Managed Care Audits and Reimbursement Demands in the Wake of the ACA

If the summer of 2017 demonstrated anything, it is that health care remains a complex and contentious industry. One of its many complications stems from the natural tension between health care providers and health care...more

CMS To Expand Use of TPE Audits Nationwide by End of 2017

by Dorsey & Whitney LLP on

Perhaps lost amid the healthcare news coverage of competing proposals regarding “Medicare for All” and the repeal of Obamacare, the Centers for Medicare & Medicaid Services (“CMS”) last month announced the expansion of its...more

SuperVision - Labor & Employment Law Insights - September 2017

...This issue of SuperVision is dedicated to questions our friends and clients may have regarding insurance and benefit topics. While not a common part of the Labor & Employment field, Spilman prides itself on having...more

Targeted Probe and Educate – CMS Changes Its Approach to Auditing

by Baker Ober Health Law on

Medicare providers and suppliers will now be subject to Targeted Probe and Educate (TP&E) audits beginning this fall. These TP&E audits will focus on limited audits of individual providers and provider education. This new...more

Inspector General Audit Could Impact Skilled Nursing Facilities

by Ruder Ware on

Skilled nursing facilities (SNF) may see even more scrutiny from the Centers of Medicare and Medicaid Services (CMS) because of a recent audit conducted by the Office of Inspector General of the U.S. Department of Health and...more

Healthcare Law Update: September 2017

by Holland & Knight LLP on

OIG Advisory Opinions - Manufacturer's Free Replacement of Spoiled Pharmaceutical Products Authorized - On Aug. 25, 2017, the U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG)...more

OIG Claims CMS Paid $729 Million in Erroneous EHR Incentive Payments

by Baker Ober Health Law on

In a June 12, 2017 report entitled, Medicare Paid Hundreds of Millions in Electronic Health Record Incentive Payments That Did Not Comply With Federal Requirements, the Department of Health and Human Services, Office of...more

Medicare Two-Midnight Rule and Observation Status Updates

by Baker Ober Health Law on

What's new from Medicare in the areas of the Two-Midnight rule and observation services? CMS recently published updates to a Medicare manual reflecting clarifications to its Two-Midnight policy, a Medicare Quality Improvement...more

Health Care E-Note - January 2017

by Burr & Forman on

On October 4, 2016, The Centers for Medicare and Medicaid Services ("CMS") released the final rules regarding the requirements of participation for skilled nursing facilities. One of the most significant changes to the...more

CMS Audit Practices: How false can you get?

by McAfee & Taft on

Caring Hearts Personal Home Care Services provided physical therapy and skilled nursing services to homebound Medicare patients. During an audit, CMS determined that Caring Hearts provided services to patients who didn’t...more

Manatt on Health Reform: Weekly Highlights - July 2016 #3

Massachusetts’s Marketplace eliminates cost-sharing for addiction treatment in subsidized QHPs; Montana cuts its uninsurance rate in half; and a Kaiser report identifies the 50 most costly drugs for Medicaid....more

Next Steps: Helping Your Organization Implement the New Medicare Overpayment Rule - Part II

by Womble Bond Dickinson on

On February 12, 2016, the Centers for Medicare & Medicaid Services (“CMS”) published a final rule that explains the requirements for providers and suppliers reporting and returning overpayments under Medicare Parts A & B (the...more

Hospice Providers – Step Up to the “MIC”

by Poyner Spruill LLP on

After a period of relative calm on the audit front, many signs point to an increase in audit activity. According to the Program Integrity Section of the Division of Medical Assistance, a Medicaid Integrity Contractor (MIC)...more

3 Takeaways from the Recent Ruling on Statistical Extrapolations in CMS Audits

by Polsinelli on

On Jan. 20, 2016, a federal district court in the Western District of Texas affirmed a decision of the Medical Appeals Council (Appeals Council) affirming a CMS contractor’s extrapolation methodology used to assess an...more

CMS Proposes Expansion of RAC Program to Medicare Part C – All Medicare Advantage Contracts to Become Target of RADV Audits

On December 22, 2015, the Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI) and a proposed statement of work (SOW) seeking industry feedback on the expansion of the recovery audit...more

GAO Recommends Improved CMS Nursing Home Quality Oversight

by Reed Smith on

The Government Accountability Office (GAO) recently issued a report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight,” examining changes in reported nursing home quality and related CMS oversight...more

GAO Says CMS Should Improve Nursing Home Data and Oversight

by King & Spalding on

On November 30, 2015, the Government Accountability Office (GAO) released a report on nursing home quality. The Report examines (1) the extent to which reported nursing home quality has changed in recent years and the...more

Developments in Long-Term Care Q2 2015

by Hodgson Russ LLP on

The following summary highlights key federal court developments and administrative decisions involving skilled nursing facility survey and related issues during the second quarter of 2015....more

Meaningful Use Audits: Proactive Tips for Success

by Burr & Forman on

For health care professionals who began accepting Meaningful Use incentive money at the outset of availability under the Medicare option in 2011, the year 2015 is an important year. If the provider has met all core...more

Recent OIG Audits of Home Health and Hospice Surveys May Signal Increased Scrutiny on Worker Qualifications

by Foley & Lardner LLP on

Recent audits by the Department of Health and Human Services Office of Inspector General (“OIG”) conclude that state survey agencies in a number of states and a leading national accrediting agency serving the home health and...more

Health Care E-Note - June 2015

by Burr & Forman on

In This Issue: - Why, Again, Do You Think That Worker is an Independent Contractor? - I-9 and E-Verify Compliance Practices for Temporary Labor and Contractors - Excerpt From Why, Again, Do You Think That...more

Bipartisan Spotlight on Medicare Advantage Risk Adjustment Fraud Likely to Spur Audits

Potential fraud and abuse in the Medicare Advantage Program (“MA Program”) has become the focus of two senior-ranking Senators on each side of the aisle—Chuck Grassley (R-Iowa) and Claire McCaskill (D-Mo.)—and this attention...more

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