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Centers for Medicare & Medicaid Services (CMS) Audits

King & Spalding

OIG Audit Finds Medicare Overpaid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation

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On August 12, 2024, OIG announced the results of an audit of payments made to hospitals for inpatient claims with the Medicare Severity Diagnosis-Related Groups (MS-DRGs) that require ninety-six hours of consecutive...more

Health Care Compliance Association (HCCA)

[Virtual Event] Research Compliance Conference - November 12th, 8:00 am - 5:00 pm CT

Stay on top of developments in healthcare research compliance - Whether you missed the 2024 in-person Higher Education & Healthcare Research Compliance Conference in New Orleans, or are looking for additional insights...more

Proskauer - Health Care Law Brief

No Surprises Here!  CMS Audit Uncovers Non-Compliance by Aetna in Calculation and Disclosure Requirements Under the No Surprises...

In a recent audit, the Centers for Medicare & Medicaid Services (“CMS”) uncovered non-compliance by Aetna Health Inc. of Texas (“Aetna”) in calculating key payment information for air ambulance services under the No Surprises...more

Polsinelli

Provider Reimbursement Disputes Go Back to 1984 Following Supreme Court’s Regulatory Reset

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One could forgive the healthcare industry for thinking someone drove Doc Brown’s DeLorean time machine through One First Street when it awoke on Friday, June 28, to a blast from the past....more

Gardner Law

CMS Audits on the Horizon: Prepare for Increased CMS Audits Under the Sunshine Act

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Historically, the Centers for Medicare and Medicaid Services (“CMS”) has not aggressively pursued enforcement activity under the Sunshine Act. However, this may change in 2024. Late last year, CMS updated its Open Payments...more

ArentFox Schiff

Fast Five: Important Law and Policy Updates for US Health Care Transactions

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With the end of the first quarter of 2024, we highlight five developments, changes, or challenges that health systems, hospitals, nursing homes, clinics, physician practices, health insurers, and other health care providers,...more

NAVEX

Addressing Cybersecurity Expectations in Healthcare

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2024 is shaping up to be a very active year for regulatory and enforcement developments in the healthcare industry – developments that concern not just hospitals and nursing facilities, but many non-healthcare companies as...more

Gardner Law

CMS Auditing Companies for Sunshine Compliance: Are You Ready?

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As the Sunshine Act reporting deadline of March 31, 2024 draws near, medical device and pharmaceutical companies are gearing up for their Sunshine Act reporting. Are you prepared for a Sunshine Act audit? Reporting...more

Holland & Knight LLP

OIG to Audit CMS Oversight of Nursing Home Surveys by Third-Party Contractors

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The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), a top federal watchdog tasked with overseeing Medicare, Medicaid and other HHS programs, recently announced that it will audit the...more

King & Spalding

CMS Publishes Final Rule Regarding CMPs for Late Reporting by Medicare Secondary Payers

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On October 11, 2023, CMS published a final rule (the Final Rule) regarding how and when CMS will impose civil monetary penalties (CMPs) for Medicare secondary payers (MSPs) that untimely report required information. The Final...more

King & Spalding

OIG Announces Results of Hospital Transfer Payment Policy Audit

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On Friday, October 6, 2023, OIG announced the results of an audit performed on the Medicare Part A hospital transfer policy for discharges to post-acute care (PAC). The hospital transfer policy, which was established in...more

American Conference Institute (ACI)

[Event] 2nd Annual Legal, Regulatory and Compliance Summit on Medicare Advantage - November 2nd - 3rd, Nashville, TN

Hosted by American Conference Institute, the 2nd Annual Legal, Regulatory and Compliance Summit on Medicare Advantage returns for another exciting year with curated programming that will address the latest oversight and...more

Stevens & Lee

False Claims Act’s Materiality Requirement Spotlighted Again in Recently-Decided Third Circuit Case

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The False Claims Act’s (FCA) materiality requirement as articulated by the U.S. Supreme Court in Universal Health Servs., Inc. v. United States ex rel. Escobar, 579 U.S. 176 (2016) was again front and center, this time in a...more

Health Care Compliance Association (HCCA)

[Event] 2024 Managed Care Compliance Conference - January 29th - 30th, Coronado, CA

Explore the unique issues that are pertinent to managed care professionals! This annual event dedicated to compliance management for health plan providers is returning to an in-person format for 2024. Join your peers and...more

Foley & Lardner LLP

HRSA Uninsured Program COVID-19 Services: What Were the Standards to Determine Uninsured Status?

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The Health Resources and Services Administration (HRSA) Uninsured Program (UIP), which reimbursed providers for provision of COVID-19 related services to uninsured individuals, paid out more than $24.5 billion in claims....more

Morgan Lewis - Health Law Scan

Hospice in the Crosshairs: Medicare’s Enhanced Oversight and Newly Announced Audit Pilot

For over a year, the hospice industry, legislators, and state and federal regulators have expressed concerns about the fast growth and potentially unscrupulous activities of new hospices in several states in particular. Those...more

Epstein Becker & Green

Local Law Amends New York City Charter and Establishes an Office of Healthcare Accountability

On June 8, 2023, the New York City Council passed a bill focused on healthcare accountability, with the goal of increasing access to healthcare services for New Yorkers. Entitled the Healthcare Accountability & Consumer...more

BakerHostetler

Government Scrutiny Expected of Providers That Furnished OTC COVID-19 Tests to Medicare Patients

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In April 2022, CMS announced an initiative to pay for Medicare beneficiaries to receive free OTC COVID-19 test kits. Specifically, Medicare established a demonstration project to pay various eligible healthcare providers to...more

ArentFox Schiff

Kitchen Sink MDRP Proposed Rule Radically Changes Best Price Determination Resulting in Financial and Operational Challenges for...

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On May 26, 2023, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule titled: “Medicaid Program: Misclassification of Drugs, Program Administration and Program Integrity Updates Under the Medicaid Drug...more

King & Spalding

Major Shift in Best Price Proposed in Grab Bag of MDRP Reforms

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The title of CMS’s May 26 proposed rule, “Misclassification of Drugs, Program Administration and Program Integrity Updates Under the MDRP,” buries the lede. Amid twenty Medicaid Drug Rebate Program-related proposals—some...more

Husch Blackwell LLP

I Understood There Would Be No Math: Audits, Extrapolations, and a New Set of Rules

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Audits that employ statistical extrapolation can turn a handful of claim denials into a liability of hundreds of thousands or millions of dollars. After years of relative quiet, the statisticians are back. The Centers for...more

Manatt, Phelps & Phillips, LLP

[Webinar] Navigating the Rapidly Changing Medicare Advantage Regulatory Landscape - April 11th, 1:00 pm - 2:00 pm ET

Medicare Advantage (MA) plans now cover about half of Medicare beneficiaries, and with that enrollment growth has come increased scrutiny from federal and state regulators. As federal regulators complete a busy season of...more

Ballard Spahr LLP

HHS OIG to Review CMS Citations

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Summary - The Department of Health and Human Services Office of Inspector General (HHS OIG) has announced its intention to comprehensively review nursing home citations issued by the Centers for Medicare and Medicaid...more

Groom Law Group, Chartered

CMS Medicare Advantage RADV Final Rule: No Fee-For-Service Adjuster, May Extrapolate Audit Findings Beginning with PY 2018

More than four years after it was proposed, on February 1, 2023 the Centers for Medicare & Medicaid Services (CMS) published the long-awaited risk adjustment data validation (RADV) Final Rule (Final Rule) that will affect...more

Bass, Berry & Sims PLC

The ABCs of Medicare and Medicaid Claims Audits: Responding to Audits and Potential Consequences from Negative Audits

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As addressed in the first installment of this three-part series, healthcare providers face potential audits from an increasing number of Medicare and Medicaid contractors. Failing to respond properly can lead to significant...more

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