Medicare, Medicaid & Private Payor Updates

UPIC / ZPIC / Health Integrity Opioid Audits and Audits of Other High Risk Drugs.

Medicare, Medicaid & Private Payor Updates /

(June 23, 2017): Opioid audits of the prescribing practices of pain management physicians are on the rise. As the Department of Health and Human Services (HHS), Office of Inspector General (OIG), noted in its report “High Part D Spending o Opioids and Substantial Growth in Compounded Drugs Raise Concerns,” 30% of Medicare beneficiaries have at […]

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False Claims Act Penalties Have Almost Doubled!

Medicare, Medicaid & Private Payor Updates /

(June 21, 2017): Over the last year, the False Claims Act penalties have almost doubled. This is especially important when you consider the fact that the False Claims Act is the primary civil enforcement tool used by the U.S. Department of Justice to fight fraud committed against government programs by individuals and entities. Often referred

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UPIC Claims Audits of Medicare Services are Underway! Are You Ready?

Medicare, Medicaid & Private Payor Updates /

(Updated March 20, 2020): Historically, the Centers for Medicare and Medicaid Services (CMS) has relied on a network of private contractors to handle the program integrity functions for both the Medicare and Medicaid programs. Over the years, these private contractors have taken on increasingly significant roles in the detection and audit of instances of fraud,

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Medicare Chiropractic Audits are Increasing!

Medicare, Medicaid & Private Payor Updates /

(June 5, 2017): Despite the fact that only three treatment services are covered by Medicare, the number of Medicare chiropractic audits conducted by the Department of Health Human Services (HHS), Office of Inspector General (OIG), has remained high over the last decade and is anticipated to grow throughout 2017 and 2018. As you are aware,

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Private Insurance Payors are Aggressively Conducting Acupuncture Audits

Medicare, Medicaid & Private Payor Updates /

(May 26, 2017): Over the past decade, the number of patients utilizing one or more complimentary or alternative care modalities has steadily increased. As patient demand for such services has grown, the percentage of payors including acupuncture in their plans as a covered service has also increased. For over a decade now, most private payor

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Exclusion Screening-OIG Screening: The New “Seventh Element” of Compliance.

Compliance, Medicare, Medicaid & Private Payor Updates /

(May 17, 2017): Exclusion screening-OIG screening duties are now more important than ever before! The recently issued Resource Guide for Measuring Compliance Program Effectiveness” a product of Office of Inspector General staff and compliance professionals roundtable discussions, reconfigures the traditional “Seven Elements of an Effective Compliance Program” by making the “Screening and Evaluation of Employees, Physicians,

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OIG And DOJ Issue Important New Compliance Guidance

Compliance, Medicare, Medicaid & Private Payor Updates /

Compliance Guidance (April 14, 2017) Recently, the Office of Inspector General of the United States Department of Health and Human Services (OIG) and the Criminal Division of the Fraud Section at the United States Department of Justice (DOJ) have issued guidance on measuring the effectiveness of corporate compliance programs.  In February, DOJ placed on its

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Are you Ready for the Next Round of CMS Revalidation?

Medicare, Medicaid & Private Payor Updates /

(March 17, 2017): The Centers for Medicare and Medicaid Services (CMS) recently announced that it will be initiating its next round of CMS revalidation requests to all Medicare enrolled providers and suppliers. Current law and regulations require providers and suppliers to revalidate their enrollment with Medicare every five years (every three years for DME suppliers).

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HHS Issues Final Rule to Address Record High Medicare Appeals Backlog

Medicare, Medicaid & Private Payor Updates /

(January 20, 2017): The Medicare appeals backlog has reached its all-time worst. If you’re a healthcare provider or supplier waiting for a hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Medicare Appeals (OMHA) – the third level of the Medicare appeals process – you’ve likely been waiting years to

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CMS Seeks to Overhaul Medicare Claims Appeal Process

Medicare, Medicaid & Private Payor Updates /

(July 18, 2016): The Centers for Medicare and Medicaid Services (CMS) has announced a series of proposed changes to the Medicare claims appeal process. The new rules primarily impact the Administrative Law Judge (ALJ) level of review, and CMS has indicated that the purpose of these changes is to help reduce the backlog of pending

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