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Category Archives: Medicare

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OIG Proposed Rule on New Civil Money Penalty Authorities

Posted in Fraud and Abuse, Medicare

The Office of Inspector General (OIG) today issued a proposed rule which would amend the federal civil monetary penalty (CMP) regulations addressing new CMP authorities created under the Affordable Care Act.  The revised regulations would allow for civil penalties, assessments, and exclusion from Medicare for and of the following: Failure to grant OIG timely access… Continue Reading

New Tool For HIPAA Security Assessment

Posted in Health Reform, Medicare, Practice Management

This past Friday, the Office of the National Coordinator for Health Information Technology, in collaboration with the HHS Office for Civil Rights and HHS Office of the General Counsel, developed a HIPAA “Security Risk Assessment Tool.”  The Security Risk Assessment Tool is a downloadable program that was developed to assist providers in performing HIPAA security… Continue Reading

CMS to Evaluate Release of Medicare Physician Payment Data on a Case-by-Case Basis

Posted in Medicare

CMS announced this week that it is modifying its longstanding policy regarding the release of Medicare physician payment data in response to Freedom of Information Act (FOIA) requests.  Since 1980, CMS’ policy has been that, for privacy reasons, it would not release Medicare payment data specific to individual physicians.  However, according to a pronouncement in the Federal… Continue Reading

Medicare Advantage Plans Terminating Physician Participation Without Explanation

Posted in Health Reform, Medicare

In recent months I have had a number of physician clients contact me to tell me that they have unexpectedly been dropped from one or more Medicare Advantage plans with which they have participated with no issue for, in some case, years.  These physicians are left somewhat bewildered because these terminations are being done without cause and without explanation.  A… Continue Reading

Physician-Hospital Integration Strategies

Posted in Health Reform, Medicare, Physician Compensation, Practice Management

As the implementation of the federal Affordable Care Act (ACA) continues in fits and starts, healthcare providers are scrambling to best position themselves to accommodate anticipated and developing payment models.  Unfortunately no one really knows what these new payment models will look like or how they will ultimately work.  It is apparent, however, that most… Continue Reading

Budget Sequester Brings Bad News for Physicians

Posted in Medicare

Unless you’ve been living under a rock for the last several weeks, you are likely well aware of the budget sequester that took effect on March 1.  The sequestration requires "across the board" cuts in federal spending.  That, in and of itself, may not be such a bad news.  However, what you may not be… Continue Reading

DOJ Announces Record Fraud Settlement Against Physician

Posted in Fraud and Abuse, Medicare

Yesterday the U.S. Department of Justice announced that it has entered into a $26M False Claims settlement with a dermatologist in Florida.  According to the DOJ, this is one of the largest False Claims settlements against an individual in history.  The physician was accused of allegedly accepting kickbacks from a pathology lab and billing for medically… Continue Reading

MedPAC Site-Neutral Payment Proposal Could Level Outpatient Reimbursement Playing Field

Posted in Medicare

It’s no secret that Medicare pays significantly more for certain services when they are performed in a hospital outpatient department than when they are performed in a physician office.  In fact, this is one of the reasons privately practicing physicians have been folding up shop in favor of hospital employment.  Hospitals can make more from these services than… Continue Reading

Feds Announce Largest Single Physician Medicare Fraud Bust

Posted in Fraud and Abuse, Medicare

I have been speaking with physicians for years about the importance of developing effective fraud and abuse compliance programs in their practices and I often still get the same response:  The government is only interested in the big fish like pharmaceutical manufacturers and hospitals -physicians are under the radar.  Well, contrary to popular belief, it appears that there… Continue Reading

Fizzle But Not Much Bang: Medicare Fraud Prevention System Early Results Not Great

Posted in Fraud and Abuse, Medicare

In June of 2011, I reported on this blog about a software program being launched by the federal Department of Health and Human Services to use a technology called predictive modeling to identify fraudulent and abusive billing practices on a prepayment basis.  The program, known as the Fraud Prevention System, was funded through the The… Continue Reading

The “Fix” That Saved Christmas

Posted in Medicare

In a last ditch effort to salvage their Holiday vacation plans, the U.  S.  House of Representatives has approved legislation which will delay the 27% Sustainable Growth Rate (SGR) cut to the Medicare Physician Fee Schedule.  The good news of course is that CMS will not need to put a hold on physician payments starting January 1 as they… Continue Reading

Federal Prosecutors Continue Focus On Health Care Fraud

Posted in Fraud and Abuse, Medicare

Federal prosecutors continue to focus their efforts on preventing health care fraud, as evidenced by a recent case arising in Texas. Earlier this year, a Houston doctor (Dr. Christina Clardy) was convicted of three counts of mail fraud, 14 counts of health care fraud and one count of conspiracy to commit health care fraud – all relating to over $45 million in false billings to Medicare and Texas’ Medicaid programs.