Search Results for: private overpayment

Structural Denial of Due Process in HCQIA Peer Review Proceedings

Medicare, Medicaid & Private Payor Updates /

(October 12, 2015): The Federal HCQIA peer review statute affords peer-reviewing bodies and their members legal immunity from liability from suits by the physicians they discipline, so long as their peer-review processes include certain due process rights for the accused physician. These due process rights are expressed as a right to a hearing, and are […]

Structural Denial of Due Process in HCQIA Peer Review Proceedings Read More »

The Medicare Appeals Process is Broken

Medicare, Medicaid & Private Payor Updates /

(May 5, 2015): As the health care providers and suppliers we represent can easily attest, there are serious problems plaguing the current Medicare appeals process. Rubber-stamp denials by contractors[1] at lower levels of appeal, the failure of Medicare contractors to apply the correct coverage rules and requirements when assessing a claim, and lengthy delays in

The Medicare Appeals Process is Broken Read More »

Dental Claims False Claims Act Liability

Dental Audits & Compliance /

(March 6, 2015): As we have seen in recent years, Medicaid audits resulting in dental claims False Claims Act liability are increasing around the country.  Earlier this week, the U.S. Attorney’s Office, the U.S. Department of Health and Human Services. Office of Inspector General (HHS-OIG), and the Maine Attorney General’s Office announced the settlement of

Dental Claims False Claims Act Liability Read More »

The FY 2016 Budget Proposes Medicare Appeals Process Reforms

Medicare, Medicaid & Private Payor Updates /

(February 27, 2015): On February 2, 2015, President Obama released his fiscal year 2016 budget proposal. This latest proposal affects a significant number of Federal health care programs and includes over $1 trillion allocated to the U.S. Department of Health and Human Services (HHS). More than 85 percent of HHS’s budget is devoted to programs

The FY 2016 Budget Proposes Medicare Appeals Process Reforms Read More »

CMS Implements RAC Program Improvements

Medicare, Medicaid & Private Payor Updates /

(January 9th, 2015) Health care providers increasingly complain that the Recovery Audit Program creates numerous administrative and financial burdens for those participating in the federal Medicare program. Providers continue to advocate for numerous changes to the program, especially those that will reduce their burden when dealing with Recovery Audit Contractors (RACs). In response to these

CMS Implements RAC Program Improvements Read More »

Texas Medicaid Dental Fraud: Is the State Partly to Blame?

Dental Audits & Compliance /

(August 12, 2014): Texas Medicaid dental fraud has been an ongoing concern of both federal and state law enforcement agencies. As set out in an August 2014 report titled “Texas did Not Ensure that the Prior Authorization Process was Used to Determine the Medical Necessity of Orthodontic Services,” the U.S. Department of Health and Human

Texas Medicaid Dental Fraud: Is the State Partly to Blame? Read More »

Health Care Compliance Program Development, Review & Implementation

(July 18, 2014): Over the last decade, Compliance Programs have become an essential part of the way large and mid-sized health care providers conduct business.  In recent years, small health care providers have followed suit, and Compliance Program development, review and implementation has become a priority if the provider intends on staying within the four

Health Care Compliance Program Development, Review & Implementation Read More »

How to Conduct a GAP Analysis of Your Health Care Practice

GAP Analyses are routinely used in practically every industry to assist an organization in identifying whether corrective actions are needed in order to bring an entity to an acceptable level of legal and professional compliance. Our health care clients have consistently found that a GAP Analysis of their practices can be an invaluable compliance tool. A

How to Conduct a GAP Analysis of Your Health Care Practice Read More »

Medicare ALJ Appeals of Denied Home Health Claims

Home Health & Hospice /

(February 11, 2014): Has a Zone Program Integrity Contractor (ZPIC) denied your home health claims? If you believe that these denials are unwarranted, your home health agency (HHA) may challenge the denials through Medicare’s administrative appeals process. Medicare’s appeals process provides five levels of appeal. The first four levels of appeal are before different administrative

Medicare ALJ Appeals of Denied Home Health Claims Read More »