Medicare, Medicaid & Private Payor Updates

Amniotic Membrane - Featured Image - Liles Parker

Navigating Amniotic Tissue / Amniotic Membrane / Skin Substitute Audits and Investigations

(August 14, 2024): For almost a century, health care providers have used amniotic tissues / amniotic membranes in the care and treatment of wounds.[1] In recent years, health care providers have greatly expanded the scope of therapeutic applications employing amniotic tissues / amniotic membranes in wound care procedures. These developments have led to increased scrutiny […]

Navigating Amniotic Tissue / Amniotic Membrane / Skin Substitute Audits and Investigations Read More »

Health Care Provider Risks of Chelation Therapy - Liles Parker

Health Care Provider Risks When Ordering and Billing Chelation Therapy Services

(January 25, 2024): Although chelation therapy[1] has played an important role in mainstream medicine for many years,[2] it is still considered by many clinicians and regulators to fall within the category of “Complementary and Alternative Medicine.” Proponents of chelation therapy in alternative medicine practices have supported its use in treating Alzheimer’s disease,[3] Parkinson’s disease, multiple

Health Care Provider Risks When Ordering and Billing Chelation Therapy Services Read More »

Texas HHSC-OIG is Ramping-Up its Investigations of Medicaid Pediatric Telemedicine Claims

(June 27, 2023): In the State of Texas, Medicaid plays a significant role in providing healthcare services to a large portion of the population. With more than 5.9 million[1] Texans (approximately 18.9% of the current population[2]) enrolled in Medicaid, it is an essential program for qualifying low-income citizens. In Texas, Medicaid costs taxpayers over $40

Texas HHSC-OIG is Ramping-Up its Investigations of Medicaid Pediatric Telemedicine Claims Read More »

COVID-19 Vaccine Mandate Update

(June 20, 2023): In response to the recent public health crises, the Centers for Medicare & Medicaid Services (CMS) first implemented a vaccine mandate for healthcare providers in late 2021. This policy was an effort to safeguard the vulnerable populations served by healthcare workers. This directive required that all healthcare workers, volunteers and third-party contractors

COVID-19 Vaccine Mandate Update Read More »

HHS Departmental Appeals Board (DAB) Appeals

(June 15, 2023): The Department of Health and Human Services (HHS) is enormous, employing more than 80,000 individuals[1] who work in a dozen operating divisions and an even greater number of independent offices that report directly to the Office of the Secretary.[2] One of these independent offices is the HHS Departmental Appeals Board (DAB or

HHS Departmental Appeals Board (DAB) Appeals Read More »

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

Medicare Advantage Plans are Aggressively Denying Claims – Administrative Appeals are Growing Read More »

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

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

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

Medicare Advantage SIU Audits and Investigations are More Prevalent Than Ever Read More »

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

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

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

Enforcement Efforts Targeting Aquatic Therapy Providers and CPT Code 97113 Claims Read More »