Medicare, Medicaid & Private Payor Updates

The Recovery Audit Contractor Program Continues to Expand its Medicare Footprint

Medicare, Medicaid & Private Payor Updates /

(November 26, 2012): The Medicare Fee-for-Service (FFS) program consists of numerous payment systems, with a complex network of contractors that process more than one billion claims submitted by more than one million healthcare providers each year.[1] Medicare providers include hospitals, physicians, skilled nursing facilities, labs, ambulance companies, and durable medical equipment, prosthetics, orthotics, and supplies

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Personal Care Service Agencies and Personal Care Service Attendants are Increasingly Targeted in Medicaid Fraud Investigations

Medicare, Medicaid & Private Payor Updates /

(September 15, 2023): Medicaid funding for personal care services allows those that need help for activities of daily living to remain in their homes and receive care from qualified individuals rather than have to live in institutional settings.[1] This is also a benefit to Medicaid, as it reduces the demand and costs for institutional and

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The OIG Identifies Substantial SNF Medicare Overpayments

Medicare, Medicaid & Private Payor Updates /

(November 18, 2012): A recent report issued by the Department of Health and Human Services, Office of Inspector General (OIG), OEI-02-09-00200 (Report), found substantial errors in payments made by Medicare to skilled nursing facilities (SNFs) for FY 2009. The Report also found substantial errors in SNF reporting on the Minimum Data Set (MDS) forms. Specifically,

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The Medicare Audit Improvement Act Appears Promising at First Glance. Is it Really the Answer?

Medicare, Medicaid & Private Payor Updates /

(November 12, 2012): The AHA Supports the Medicare Audit Improvement Act of 2012. Is this Legislation Going to Help Physicians or Not? On October 16, 2012, a new bill was introduced by Representative Sam Graves (R-MO) entitled the “Medicare Audit Improvement Act of 2012”. This legislation was immediately supported by the American Hospital Association (AHA),

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Is the Secretary for the Department of Health and Human Services Going to Issue an 1135 Waiver?

Medicare, Medicaid & Private Payor Updates /

(November 2, 2012): As we recently discussed before the East Coast arrival of Hurricane Sandy, Social Security Act Section 1135 Waivers may ultimately be available for healthcare providers in affected areas of New York, New Jersey, Delaware, New England, and surrounding states. 1135 Waivers exist to temporarily waive billing and participation requirements for healthcare providers

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Individual Liability for Medicare Overpayment Claims

Medicare, Medicaid & Private Payor Updates /

(October 19, 2012): This article addresses the case where an individual or “natural person” owns an interest in a Medicare health care provider which is incorporated[1] under the laws of a state, as a corporation, limited liability company, limited partnership, or another type of legal person. The individual may be a shareholder, member, limited partner,

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A CMS ZPIC Contract is Quite Lucrative

Medicare, Medicaid & Private Payor Updates /

(September 26, 2012): From the start, Zone Program Integrity Contractors (ZPICs) have worked to separate themselves from their proverbial “bounty hunter” peers – Recovery Audit Contractors (RACs). As you may know, ZPICs are paid on a contractual basis by the Centers for Medicare & Medicaid Services (CMS), instead of by how much money they return

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FCA Express Certification Liability Theory

Medicare, Medicaid & Private Payor Updates /

(September 24, 2012): There are 3 recognized legal theories under which False Claims Act (FCA) liability may be established – the FCA Express Certification, Implied Certification, and Worthless Services theories. As you may know, the FCA is the government’s primary fraud fighting tool, and prohibits the presentation of false claims for payment by the government.

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HHS-OIG Finds ZPICs May Have Conflicts of Interest

Medicare, Medicaid & Private Payor Updates /

(September 13, 2012): Many physicians and other health care providers around the country are reeling from post-payment and pre-payment assessments conducted by Zone Program Integrity Contractors (ZPICs). As ZPIC audits are being conducted, an issue has recently arisen regarding their independence. According to a recent report issued by the Office of Inspector General (OIG), the

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Texas Medical Privacy Act Takes Effect

Medicare, Medicaid & Private Payor Updates /

(September 11, 2012): They say that “Everything is Bigger in Texas,” and its law concerning medical privacy is no exception. The Texas Legislature recently enacted the Texas Medical Privacy Act (TMPA)[1], also known as the Texas HIPAA law. The new law substantially increases the compliance burden on medical and service providers, suppliers, business associates, third

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