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
On July 10, the Centers for Medicare and Medicaid Services (CMS) released its annual Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule, which provides...more
CMS estimates that between 2017 and 2021, Medicare Part A improperly paid $23.9 billion for inpatient hospital stays, with $7.8 billion attributable to short stays that did not qualify for Medicare Part A. On June 13, 2024,...more
The Office of Inspector General (OIG) recently issued a new favorable OIG Advisory Opinion, concluding that, although the proposed arrangement (“Proposed Arrangement”) between a Medicare Supplement insurer (“MediGap Plan”)...more
The Office of Inspector General (OIG) recently issued two identical favorable OIG Advisory Opinions, concluding that, although the proposed arrangement (“Proposed Arrangement”) between a Medicare Supplement insurer (“MediGap...more
As most of you already know, the Centers for Medicare & Medicaid Services (CMS) recently released two Medicare payment regulations: the Calendar Year (CY) 2024 Physician Fee Schedule (PFS) proposed reg and the CY 2024...more
On June 16, 2023, the U.S. Supreme Court affirmed that the DOJ properly secured a dismissal of a whistleblower suit accusing Executive Health Resources Inc. of violating the False Claims Act by improperly billing Medicare....more
On June 16, 2023, in United States, ex rel. Polansky v. Executive Health Resources, Inc., the US Supreme Court addressed the government’s authority to dismiss a qui tam False Claims Act (FCA) suit over a relator’s objection...more
On December 2, 2022, Health & Human Services issued guidance (HHS) delaying the requirement that convening providers include co-provider charges in their good faith estimates for self-pay patients. Previously, the requirement...more
The United States Supreme Court recently agreed to hear a case interpreting the False Claims Act (“FCA”) that may affect the government’s involvement in pending and future matters. To resolve a circuit split, the Court will...more
As of January 1, 2022, certain provisions of the “Consolidated Appropriations Act,” commonly referred to as the “No Surprises Act” (Act), are in effect. The Act amends the Public Health Service Act, Employee Retirement Income...more
Get the latest updates on government initiatives related to physicians and clinics - HCCA’s Clinical Practice Compliance Conference provides insights, updates, and strategies that are pertinent to developing and managing...more
The Centers for Medicare & Medicaid Services (CMS) on July 19, 2021, released its calendar year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed...more
On March 10, 2021, the New York State Department of Financial Services (“DFS”) issued Insurance Circular Letter No. 4 (“Circular Letter”), which both explains modifications to the Insurance Law and the Public Health Law...more
Compliance Today (March 2021) - The Centers for Medicare & Medicaid Services (CMS) has provided the following compliance notice: “In a recent report, the Office of Inspector General (OIG) determined that Medicare made...more
Fresenius to defend itself from FCA suit following whistleblower allegations - A former employee alleges Fresenius engaged in arrangements with hospitals and nephrologists to ensure patient referrals to its dialysis...more
In this week’s episode, Gary Qualls discusses a recent case decided in the Western District of Louisiana, which highlights how the application of the arbitrary and capricious standard as applied to payor coverage...more
On April 9 and 10, 2020, the Centers for Medicare and Medicaid Services (CMS) updated and revised their COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing....more
Report on Medicare Compliance 29, no. 12 (March 30, 2020) A federal court on March 24 ordered CMS to let Medicare patients “challenge decisions by hospitals” to change their status from inpatients to observation, dating...more
Congress has been working for months to pass legislation protecting patients from surprise medical bills that arise when insured patients unknowingly receive out-of-network (OON) care, usually when receiving emergency medical...more
On November 5, 2019, the United States District Court for the Eastern District of Pennsylvania ruled on a motion to dismiss a False Claims Act (FCA) qui tam suit filed by the United States Department of Justice, long after it...more
Report on Medicare Compliance 28, no. 40 (November 11, 2019) - CMS has given the green light to prior authorization for five types of procedures in an attempt to control “unnecessary increases” in these procedures as part...more
Health plans and their delegated IPAs are using a number of different tactics to deny payment for inpatient services by improperly classifying inpatient claims as observation or other types of outpatient status. Payers are...more
The Office of Inspector General (OIG) recently released a report after identifying that Medicare had been improperly paying for Skilled Nursing Facility (SNF) care for beneficiaries who had not met the Medicare 3-Day...more
On July 23, 2019, Judge Rosemary Collyer of the United States District Court for the District of Columbia issued an opinion ruling in favor of ten Florida hospitals in their case challenging the calculation of their Medicare...more