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managed care

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.

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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How Communications Play a Key Role in the Hospital Readmissions Reduction

Fannie Fang Executive Editor Loyola University Chicago School of Law, JD 2017   CMS has reported that Medicare expenditures amount to roughly 17 billion a year on patient readmissions alone. Studies show that almost twenty percent of all patients who are admitted to a U.S. hospital makes a repeat visit within thirty days of discharge. …
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