Category Archives: Medicare & Medicaid

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Identifying Overpayments Under the ACA’s 60-Day Rule Creates Additional Uncertainty in Determining False Claims Act Liability

Under the Affordable Care Act (ACA), healthcare providers that receive an overpayment from Medicare or Medicaid are required to report and return the overpayment to the government within 60 days after the date on which the overpayment was identified (commonly referred to as the “60-day rule”). An overpayment retained after 60 days constitutes an “obligation” for purposes of potential False … Continue Reading

Illinois Enacts Patient Notification Requirement for Observation Stays

Illinois joins a growing number of states to pass laws requiring that hospitals provide notice to patients who are placed under observation status. 210 ILCS 86/6.09b As with the recent federal NOTICE Act, the laws respond to patients not understanding the difference between observation in a hospital bed and inpatient admission. The Illinois law requires a hospital to notify … Continue Reading

Two-Midnight Rule Update

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 enforcement Recovery Audits for the Two Midnight Rule through September 30, 2015. This has now been extended through December 31, 2015 with enforcement audits of suspect non-compliant … Continue Reading

Hospitals Required to Notify Medicare Beneficiaries of Observation Status

The NOTICE Act (Notice of Observation Treatment and Implication for Care Eligibility) has been signed into law as of August 6, 2015. The Act requires hospitals to provide oral and written notice to patients within 36 hours of being placed in observation care (or, upon discharge, if sooner). The notice must explain to patients, in plain language, that they have … Continue Reading

CMS Extends Enrollment Moratorium on Home Health Agencies

The Centers for Medicare and Medicaid Services (CMS) announced that it will once again extend the moratorium on the enrollment of new home health agencies, branch locations and subunits in certain metropolitan areas of Florida, Texas, Illinois, Michigan, New Jersey and Pennsylvania. In Florida, the moratorium continues in effect in Miami-Dade, Broward, and Monroe counties. The table below identifies the … Continue Reading

CMS Publishes Notice of Proposed Rule Making Regarding Stark Law Amendments and Seeks Comment on the Issue of Stark Acting as a Barrier to Healthcare Reform

In early July, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking, amending the Physician Self-Referral Prohibitions, or Stark law. 80 Fed. Reg. 41,909-930 (July 15, 2015). The proposed rule introduces two exceptions to Stark. The first new exception, 42 C.F.R. §411.357(x), allows financial assistance to medical practices so they may be able to recruit … Continue Reading

HHS Announces First Timeline For Medicare Pay Reforms

On Monday, January 26, 2015, the Department of Health and Human Services (“HHS”) announced a timeline for moving physicians and hospitals into new payment systems and tying Medicare reimbursements to quality of care. This will affect hundreds of billions of dollars in Medicare payments (the goals apply to Medicare Parts A and B, which paid out more than $350 billion … Continue Reading

CMS Announces Enforcement of EHR Payment Adjustments in 2015

On December 17, 2014, the Centers for Medicare and Medicaid Services (“CMS”) announced that there would be reductions in Medicare reimbursement for health care providers who do not meet the CMS electronic health record (“EHR”) incentive program’s meaningful use requirements. This announcement comes in the wake of CMS’ decision in October to extend the hardship exception deadline – an exception … Continue Reading

A Quick Look at Healthcare Issues Expected to Make News in 2015

As we look into our crystal balls, we do not expect a lot of new issues in 2015. Rather, we believe that most of the significant issues will be a continuation of issues that arose in 2014 or earlier. For example, continued implementation of the Patient Protection and Affordable Care Act (the “ACA”), which was signed into law on March … Continue Reading

ACO Participation By Tax-Exempt Healthcare Organizations –Is Tax-Exempt Financing at Stake?

Does A Tax-Exempt Healthcare Organization’s Participation in an Accountable Care Organization (ACO) Adversely Affect Its Tax-Exempt Financing? IRS Notice 2014-67 Provides Guidance.

Background:

The Patient Protection and Affordable Care Act authorizes the Department of Health and Human Services (“HHS”) to establish a Medicare Shared Savings Program (“Shared Savings Program”) to promote accountability for care of Medicare beneficiaries, to improve the … Continue Reading

CMS launches database of manufacturer and GPO payments to physicians

The Affordable Care Act contains a provision known as the Physician Payments Sunshine Act, which requires the Centers for Medicare and Medicaid Services (CMS) to establish a national databank containing information on the financial relationships between physicians (which includes dentists, chiropractors, and other physician specialties) and teaching hospitals, applicable manufacturers, and group purchasing organizations (GPOs). CMS launched its Open Continue Reading

Efforts to Stop Health Insurance Fraud Through Use of Contractors Under Fire

In recent reports, from June 25, 2014 and August 13, 2014, the Government Accountability Office (GAO) highlights the mixed results achieved by the federal government’s increased efforts to crack down on health insurance fraud through the use of contractors. The government has spent upwards of $600 million a year to uncover and punish health care fraud and overpayments, but  some … Continue Reading

CMS Releases Unprecedented Amount of Medicare Billing Information, Increasing Risk Related to Fraud Lawsuits

On April 9, 2014, the Center for Medicare and Medicaid Services (“CMS”), a branch of the Department of Health and Human Services (“HHS”), released data showing utilization, payments, and submitted charges for services and procedures that were provided by physicians and other healthcare professionals to Medicare beneficiaries.  This unprecedented release of Medicare billing information seeks to improve transparency in the … Continue Reading

Department of Health and Human Services Office of Inspector General’s FY 2014 Work Plan Identifies Security of EHR Technology as New Focus

On January 31, 2014, the U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) released its annual work plan.  Not surprisingly, issues relating to Electronic Health Records (“EHRs”) continue to receive significant attention.

Pursuant to the American Recovery and Reinvestment Act of 2009, OIG received funding to evaluate whether funds received by HHS agencies and grantees … Continue Reading

Electronic Health Record (EMR) Systems – One of the Many Ways Technology is Changing Medicine

A Conversation with Brian Foster, Director of Client Solutions at CareCloud

The availability of incentive payments to providers from the Centers for Medicare and Medicaid Services (CMS) to implement electronic medical records (EMR) systems is a hot topic these days among healthcare providers. Marshall Burack, a partner in Akerman’s Healthcare Practice Group sat down with Brian Foster, director of client … Continue Reading

Providers on Prepayment Review May Now Face Exclusion from Medicare

Providers on prepayment review could be facing exclusion from Federal healthcare programs if they don’t correct the problems which caused them to be subject to prepayment review. CMS has directed its contractors to consider excluding physicians and other providers who have been on prepayment review for extended periods of time without correcting their “inappropriate behavior” from Federal healthcare programs, including … Continue Reading

“Meaningful” Errors Require Hospital System to Refund $31M

In what is reported to be the largest repayment to date involving “meaningful use” incentive payments, Naples, Florida-based Health Management Associates, Inc. (“HMA”), with 71 inpatient facilities in 15 states, including Florida, recently voluntarily notified the Centers for Medicare and Medicaid Services (“CMS”) that it erroneously certified its electronic health record (“EHR”) technology in the amount of $31 million dollars. … Continue Reading

EHR Meaningful Use Audits Come to Florida

As previously reported, the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) plans to audit healthcare providers that received incentive payments to adopt electronic health record (EHR) technology.

We have now received reports confirming that certain provider entities have been audited in Florida regarding these EHR incentive payments.  The OIG targets payments made … Continue Reading

Jury Returns Mixed Verdict in Complicated Medicaid Fraud Trial

Over five years after law enforcement agents raided the Tampa, Florida headquarters of WellCare Health Plans, a federal jury delivered a mixed verdict in the criminal trial of the company’s former top executives. The verdict, which was delivered on Monday, came after a nearly two and a half month trial and lengthy jury deliberations that were interrupted for a 10-day … Continue Reading

Health Care Solution Network Inc. Fraud Case Continues to Generate Lengthy Prison Terms

Healthcare providers continue to receive lengthy sentences from federal district court judges in the Sothern District of Florida in the wake of the Health Care Solutions Network Inc. (HCSN) community mental health center fraud. From 2004 to 2011, HCSN billed Medicare and the Florida Medicaid program approximately $63 million for purported mental health services. Fifteen individuals have been charged for … Continue Reading

New Challenge to Medicare Requirement that Ancillary Providers Obtain Physician Records to Justify Medical Necessity

For years now, ancillary providers ranging from durable medical equipment providers (DMEs), independent diagnostic testing facilities (IDTFs), and home health agencies have been required under Medicare regulations to obtain copies of referring physicians’ medical records to prove medical necessity for the items and services the physician ordered. Providers are to utilize a template “Dear Physician” letter created by CMS that … Continue Reading

Recent Judicial Activity on the Pharmacy Front

Reimbursement for the Difference Between the Brand and Generic Drug

Graphic Communications Local 1B Health & Welfare Fund “A”, et al., Appellants, vs. CVS Caremark Corporation, et al.,  State of Minnesota Court Of Appeals, Case No. A12-1555 (May 6, 2013).

A recent decision by the Minnesota Court of Appeals reversed the dismissal of a case against pharmacies for not … Continue Reading

After OIG Report, EHR Meaningful Use Audits Are Coming

The Office of Inspector General (OIG) for the Department of Health and Human Services released a report late last year claiming that the Centers for Medicare and Medicaid Services (CMS) was not doing enough to verify that only eligible providers were receiving electronic health records (EHR) incentives. Until now, CMS relied on self-reported information to decide which providers were eligible … Continue Reading

OIG Recommends Florida make $2.3M Repayment for Medicaid Overpayment Reporting Failures

The Department of Health and Human Services (HHS), Office of the Inspector General, in a report dated March 2013, has recommended that the State of Florida repay approximately $2.3M in federal funds that represent the federal share of Medicaid overpayment collected for the audit period of July 1, 2007 through June 30, 2010, and a subsequent period of July 1, … Continue Reading

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