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
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
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
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
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
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
Lawmakers in both the United States House and Senate are considering two proposals to address unexpected, patient medical bills from out-of-network providers. Often referred to as “surprise medical bills” or “balance...more
A recent report issued by OIG finding an Indiana community hospital owed over $22 million in extrapolated overpayments carries some important lessons for hospitals audited under OIG’s hospital compliance program. As described...more
To protect patients from receiving an unexpected surprise bill when they seek care at in-network facilities from out-of-network providers, Governor Brown signed AB 72: California’s surprise out-of-network law. The new law...more
Regardless of a patient’s diligence in selecting an in-network hospital, ambulatory surgery center, or other health facility for treatment, patients are still being saddled with surprisingly high medical bills that include...more
In a report released on June 17, 2016, OIG renewed its call for CMS to either eliminate the provider-based designation, which allows facilities owned by and integrated with a hospital to bill Medicare as a hospital outpatient...more
The Centers for Medicare and Medicaid Services (CMS) announced a further delay, through December 31, 2015, of the Recovery Auditors’ (RA) audits of the “Two-Midnight” Rule. Congress previously passed a law delaying...more
On July 1, 2015, the Centers for Medicare & Medicaid Services (CMS) released proposed updates to the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for Calendar Year...more
Under CMS’s modified inpatient admission guidelines adopted in the IPPS Final Rule, Part A payment is “generally inappropriate” unless the patient is admitted based on the physician’s expectation that the patient will require...more