Medicare, Medicaid & Private Payor Updates

Region B RAC CGI Announces that it will Begin Review of Eighteen Projects that Involve Medical Necessity

(August 25, 2010): CGI Technologies and Solutions, Inc., (CGI), has announced it will immediately begin reviews on 18 newly approved projects that involve the medical necessity of selected inpatient DRG payments. A complete list of the “issues” currently being examined by CGI can be found on its website. Recovery Audit Contractors (RACs), such as CGI, […]

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CMS Issues Medical Record Retention Reminder: MLM Matters SE1022

(August 17, 2010): Last week, the Centers for Medicare and Medicaid Services (CMS) issued MLM Matters SE1022, titled “Medical Record Retention and Media Formats for Medical Records” directed toward physicians, non-physician practitioners, suppliers, and other health care providers submitting claims to Medicare contractors for services provided to Medicare beneficiaries. As CMS acknowledged, medical record retention

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Multiple Texas Health Care Providers and Suppliers Charged in DOJ’s June 2024 Strike Force Takedown

(July 11, 2024): Last week, the Department of Justice (DOJ) announced that it has criminally charged 193 defendants with violations of various health care fraud statutes. The government estimates that the fraudulent schemes employed by the defendants resulted in losses of $1.6 billion to Federal, State, and private payor health care programs. These cases are

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South Texas Medicare Providers are Under the ZPIC Microscope

(July 16, 2010): If there were ever any doubts that ZPICs are going to make their presence known in South Texas now that they have replaced PSCs,those doubts can be put to rest. Health Integrity LLC, the Zone 4 contractor, is proving to be an active and aggressive auditor of physician practices, physical therapy services,

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Providers Should Exercise Caution When Handling Overpayments — More Than Likely, You Can’t Keep It, Even if the Payor Doesn’t Want it Back!

(July 15, 2010): When handling Medicare overpayments, providers must exercise caution. Since the May 2009 passage of the Fraud Enforcement and Recovery Act (FERA) and subsequent enactment of the Affordable Care Act (ACA), we’ve heard a lot about how the government looks at Medicare overpayments and how providers should handle them. Prior to the clarification

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Can a ZPIC Extrapolate the Alleged Damages in a Medicare Claims Audit?

(July 12, 2010): Can a ZPIC extrapolate the alleged damages in a case. If the ZPIC’s statistical methodology is properly handled, the extrapolation of alleged damages can be a surefire way of destroying a provider’s practice. We’ve known it for years and yet the government’s passion for statistical sampling only seems to be growing. This

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ACA Reporting and Repayment Mandates are a Real Minefield for Medicare Providers.

(July 9, 2010): Does the failure to promptly return a Medicare overpayment really warrant liability under the False Claims Act (FCA)? Congress thinks so. The Patient Protection and Affordable Care Act (also known as the “Affordable Care Act” or “ACA”) creates an obligation under the FCA whereby a Medicare provider who fails to timely report

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Identity Theft — Red Flags Rule — Treating Doctors Like Banks Is Delayed Once Again

(July 5, 2010): The Federal Trade Commission (FTC) has agreed to once again delay enforcement of its illogical and onerous identity theft Red Flags rule with respect to physicians.The Red Flags rule arose under the Fair and Accurate Credit Transactions Act of 2003 and requires “financial institutions” and “other creditors” to develop written plans to

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Enactment of Doc Fix Bill Offers Another Temporary Reprieve for Medicare Physicians

(June 28, 2010): On Friday, June 25, 2010, President Obama signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (H.R. 3962), commonly referred to as the Doc Fix, which provides yet another band-aid for our broken Medicare physician pay system. The bill replaces the 21% Medicare physician payment

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GAO Testimony Recommends CMS Improve Enrollment, Payment, and Oversight Procedures

(June 23, 2010): Yesterday we told you about recent GAO testimony before Congress regarding the impact of health care reform on HHS enforcement efforts. On the same day, GAO Health Care Director Kathleen M. King offered Congress testimony that made clear that the Centers for Medicare & Medicaid Services (CMS) continue to face substantial challenges

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