Tag:

CMS

Escobar’s Materiality Standard Shields Organizations from the Risk in Risk Adjustment Payments

Finance Director for UnitedHealth Group brought qui tam suit against UnitedHealth Group, Inc. alleging that the organization upcoded risk adjustment data resulting in increased payments (more than $1.14 billion) to UnitedHealth Group. The Department of Justice (DOJ) intervened in the case, yet UnitedHealth Group was successful in getting the primary False Claims Act Claims dismissed by arguing that the Centers for Medicare & Medicaid Services (CMS) would not have refused to make the adjustment payments had they known of the errors in the risk adjustment. The Escobar materiality standard helps clarify threshold level of risk to Managed Care Providers in attesting to their risk adjustment payments; the falsities must have had an impact on the respective payment.

My Summer with the Office of Inspector General for the U.S. Department of Health and Human Services

This summer I had the opportunity to intern with the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) in Washington, DC. I thoroughly enjoyed my time with OIG, and I learned a great deal about health care fraud, waste, and abuse. In spending my summer with OIG, I had a glimpse into the powerful regulatory bodies that protect the health care market from abuse. As I move forward with my career in regulatory work, I will take with me the invaluable experiences and skills from my internship.

Finalized Rule: Tough Love for Medicaid MCOs?

Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017   Last May, the Centers for Medicare and Medicaid Services (CMS) issued a final rule for Medicaid managed care, which told states to stop making pass-through payments to healthcare providers. Pass-through payments have played a critical role in funding safety net hospitals which …
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Compliance Spotlight: Adam Solander, Epstein Becker Green

ADAM C. SOLANDER is a Member of Epstein Becker Green’s Health Care and Life Sciences practice, in the firm’s D.C. office. Mr. Solander advises clients on data breach/cybersecurity issues across industry lines, including compliance with HITECH, HIPAA, PCI, JCAHO, CMS, ISO, NIST, and various other federal, state, and business requirements.

The following is an interview with him discussing the unique cybersecurity challenges facing the healthcare sector, and how the industry can move past HIPAA compliance to a more robust definition of privacy and security.

Understanding Medicare Documentation Requirements

Brittany Tomkies Executive Editor Loyola University Chicago School of Law, JD 2017   With more than one billion claims processed annually by the Medicare Fee-For Service (FFS) Program for more than one million health care professionals, understanding and identifying common errors encountered by Medicare Administrative Contractors (MACs) and other contractors such as Recovery Auditors (RACs) …
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CMS Issues Proposed Rule Addressing Multiple Fraud and Abuse Concerns

Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017   The Centers for Medicare and Medicaid Services (CMS) recently proposed a new rule in the Federal Register that addresses changes in Medicare payment policies. The proposed rule aims to inform providers of proper billing practices and prevent fraud and abuse.  This post …
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Medicare Advantage Audits Reveal Alleged Rampant Upcoding

Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017   Last month, the Center for Public Integrity obtained over three-dozen new Medicare Advantage (MA) audits through a lawsuit brought under the Freedom of Information Act. The audits indicate that overcharging is still a pervasive problem in the MA Program because Medicare Advantage …
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The New Medicaid Managed Care Rule and Its Effects on Compliance Programs

Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017   The Centers for Medicare and Medicaid Services (CMS) recently published a new rule for state contracts with Medicaid Managed Care Organizations (MCO). Medicaid MCOs provide comprehensive services to beneficiaries for capitated payments. The effective date of the rule was July 5, 2016. …
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An Active Summer of Healthcare Fraud Enforcement Actions

Alanna J. Kroeker Executive Editor Loyola University Chicago School of Law,  JD 2017   Unprecedented DOJ Healthcare Fraud Takedown: On Wednesday June 22, Attorney General Loretta Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Burwell announced the largest healthcare fraud takedown in history.  This action was led by the Medicare Fraud Strike …
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