News & Analysis as of

Overpayment Audits

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

Texas OIG Turns Over New Leaf: MCOs Must Turn Attention to SIUs

by Strasburger & Price, LLP on

More active SIUs may mean more scrutiny of Medicaid providers - The Texas Office of Inspector General (OIG) has just completed its first full year of reforms under a new Inspector General. 2017 may reveal whether these...more

Medical Litigation Newsletter - December 2016

by Hinshaw & Culbertson LLP on

Defending Audits Before They Happen: A Practical Guide to Documenting to Sustain A Challenge to E/M Codes - Although many believe malpractice suits to be the primary risk-management issue facing healthcare providers, an...more

False Claims Act Basics – Known Overpayment Becomes False Claim

by Ruder Ware on

The Federal False Claims Act (“FCA”) provides a very strong enforcement tool to the federal government. The FCA also provides the opportunity for whistleblowers to bring “qui tam” cases and collect a portion of the recovery...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

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

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

OIG Hospital Compliance Audits: Is Your Number Up? Are You Ready?

by Baker Donelson on

In its Work Plan for Fiscal Year 2012, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) announced it would begin reviews of Medicare payments to hospitals to determine compliance...more

CMS Changes to Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015

by Ropes & Gray LLP on

On May 19, 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule, published in the Federal Register on May 23, 2014, that sets forth changes to requirements for Medicare Advantage (“MA”) and...more

CMS's Focus on DMEPOS Fraud and Abuse Risks Continues

by Foley & Lardner LLP on

The focus by the Centers for Medicare & Medicaid Services (CMS) on Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as an area rife with unnecessary utilization and a high improper payment rates...more

Health Headlines: Also in the News - May 2014

by King & Spalding on

OIG Reports Jurisdiction H Contractors Made $3.3 Million in Overpayments for Outpatient Drugs – According to a recent OIG report, the Medicare Contractors for Jurisdiction H overpaid providers approximately $3.3...more

Extrapolating Overpayment Claims

by Burr & Forman on

Overpayment audits of physicians are common place and, indeed, should now be expected. When conducting such audits, Medicare auditors often include not only random sampling as an audit technique but have also extrapolated...more

Third Circuit Holds Judicial Review of Extrapolated Overpayment Determinations is Precluded

by King & Spalding on

On February 12, 2014, the U.S. Court of Appeals for the Third Circuit held that Federal courts do not have jurisdiction to review HHS’s determination of a “sustained or high level of payment error,” one of two possible...more

Extrapolated Medicaid Audits Continue: Be Proactive! (Or Move to West Virginia)

by Williams Mullen on

Extrapolated audits are no fun, unless you work for a recovery audit contractor (RAC). You get a Tentative Notice of Overpayment (TNO) that says the auditor reviewed 100 dates of service (DOS), found an overpayment of...more

PA Tax Law News -- June 2013

In This Issue: Home Stretch to a PA Budget; PA to Project Vendor Overpayments In Some Audits; Township Business Privilege Tax Rejected; and Pennsylvania Supreme Court Upholds IFTA Liability. Excerpt from Home...more

PA to Project Vendor Overpayments in Some Audits

The Pennsylvania Department of Revenue has performed a partial “about face” on the audit treatment of sales tax overpayments to vendors. Previously, taxpayers under audit could request credit in the audit for overpayments...more

Self-Audit Results Found Sufficient to Sustain False Claims Act Complaint

by Baker Donelson on

District Court Finds That Medical Group’s Failure to Further Investigate Audit Results May Violate Requirement to Return Overpayments - Background - Internal audits of third-party payment claims – frequently...more

Hospitals: Audits And Compliance

by Michael Volkov on

Hospitals are under intense scrutiny. The federal government knows that one sure way to reduce healthcare costs is to get hospitals to lower their costs. Hospitals feel the pinch given the need to generate revenue but know...more

OIG Reports that Millions of Medicaid Overpayments Remain Uncollected

by King & Spalding on

On February 19, 2013, the OIG published a report detailing the collection status of Medicaid overpayments. The Secretary of HHS requires CMS to collect overpayments, defined as “the amount paid by a Medicaid agency to a...more

Annual Report Shows Meteoric Rise in RAC Activity

by BakerHostetler on

On February 5, 2013, CMS issued its mandatory Recovery Audit Contractor (RAC or Recovery Auditor) program annual report, detailing overpayments, underpayments, RAC performance and savings to the Medicare program. According to...more

CMS Publishes Annual Update On Recovery Audit Activity, Says Program Returned Nearly $490 Million to Medicare Trust Fund in 2011

by King & Spalding on

On February 5, 2013, CMS sent Congress a report summarizing developments related to its Medicare recovery audit program for fiscal year (FY) 2011. According to the report (titled Recovery Auditing in the Medicare and...more

OIG Concludes in Nationwide Review of Drug That Herceptin Has Often Been Overbilled

by King & Spalding on

The HHS OIG has conducted a nationwide audit of the use and reimbursement of Herceptin (also known as trastuzumab), a Medicare-covered drug used to treat metastatic breast cancer, and has concluded in three audits released in...more

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