Medicare, Medicaid & Private Payor Updates

Medicare Advantage Plans are Aggressively Denying Claims – Administrative Appeals are Growing

(May 25, 2023): According to the latest data released by the Centers for Medicare and Medicaid Services (CMS), beneficiaries participating in Medicare Advantage[1] plans now surpass those enrolled in original Medicare plans. Slightly more than one-half[2] of the 59.82 million Medicare beneficiaries now eligible for coverage have signed up for one of the 5,261 Medicare …

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Medicare Exclusion Risks: Employing Excluded Individuals Can Result in Significant Administrative, Civil and / or Criminal Liabilities

(May 8, 2023): One of the most severe administrative sanctions available under the Social Security Act stems from the authority of the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS)[1] to “exclude” individuals and entities from participating in Federal health care programs.[2] While the Centers for Medicare and …

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Medicare Advantage SIU Audits and Investigations are More Prevalent Than Ever

Author: Ashley Morgan, Annabella Denzel (April 5, 2023): In the sphere of healthcare compliance, providers must manage audits coming from every possible authority whether it be from public agencies, a private payor, or other third-party authorities. CMS has announced that the FY 2022 fee-for-service improper payment rate was 7.46%.[1] While this is a slight increase …

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Inflation Reduction Act: What is the Impact on Healthcare Providers?

Author: Ashley Morgan, Annabella Denzel (March 30, 2023): On August 16, 2022,[1] President Biden signed the Inflation Reduction Act (IRA) into law, bringing with it plans for broad sweeping changes to tax rates, energy prices, and—most importantly for our purposes — healthcare costs. The general consensus from providers is that because the IRA’s healthcare related …

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Enforcement Efforts Targeting Aquatic Therapy Providers and CPT Code 97113 Claims

(October 3, 2022): Aquatic therapy is a common method of rehabilitation and maintenance for several types of injuries and conditions, and the practice is widely accepted by Medicare, Medicaid and many private payors. Historically, both payors and law enforcement have routinely audited aquatic therapy claims. The Centers for Medicare and Medicaid Services (CMS) initially suspended …

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Incident To Billing Practices are Under Law Enforcement’s Microscope. Are Your Incident To Billing Practices Compliant?

(September 20, 2022): In the Medicare billing context, the term “Incident To” refers to the fact that under certain circumstances, the services of non-physician, mid-level practitioners (such as Nurse Practitioners (NPs) and Physician Assistants (PAs)) are “. . . furnished as an integral, although incidental, part of the physician’s personal professional services in the course …

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Amniotic Fluid / Amniotic Membrane Tissue Audits, Investigations and Prosecutions are Continuing to Climb in 2022

(August 4, 2022): Over the past year, we have seen a significant increase in the number of Medicare administrative audits, False Claims Act investigations and criminal prosecutions by the Department of Justice (DOJ), related to the billing of allogeneic (harvested from someone else) stem cell products. Medicare and Medicaid claims stemming from amniotic liquid and …

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Balloon Sinuplasty Fraud / Balloon Dilation Fraud Prosecutions are Increasing Around the Country

(May 25, 2022): In recent years, federal regulators have initiated a significant number of audits and investigations examining the improper billing of claims for balloon sinuplasty / balloon dilation procedures by Otolaryngologists (commonly referred to as Ear, Nose and Throat (ENT) physicians. Depending on the specific facts in each case, the improper billing of balloon …

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Will Xiulu Ruan v. United States Finally Bring Some Sanity to Interpretations of the Controlled Substances Act?

(May 2, 2022): The Supreme Court last addressed violations of 21 U.S.C. §841 by a medical practitioner in 1975.[1] Since that time, several circuit courts have taken different approaches when construing the scienter requirements to prove a Controlled Substance Act violation, and how a jury may be instructed when deciding a case.  Hopefully, clarification of …

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The Criminalization of Pain – In 2022, DOJ is Aggressively Investigating and Prosecuting MDs, NPs and PAs for Violations of the Controlled Substances Act

(April 19, 2022): Despite our government’s best efforts, opioid overdose deaths in America are continuing to spiral out of control. According to the U.S. Centers for Disease Control and Prevention (CDC), during the period April 2020 through April 2021, the number of overdose deaths were more than 30% higher than the previous year. While many …

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