Health care fraud prevention and enforcement efforts recover record $4 billion; new Affordable Care Act tools will help fight fraud Joint DOJ & HHS  efforts result in largest sum ever recovered in single year; new rules under the Affordable Care Act will keep fraudulent providers and suppliers out of Medicare, Medicaid, CHIP and avoid payments […]

Includes Stark Law issues and self-disclosure of E/M upcoding issues What lawyers call “technical” Stark violations can slam hospitals because of the black-and-white nature of the statute, a fact of life that hit home for Detroit Medical Center, which agreed to pay $30 million to resolve false claims allegations arising from sweetheart deals with referring […]

Medical Necessity Reviews Approved for Some New DRGs DCS Healthcare, the Recovery Audit Contractor (RAC) for CMS Region A, posted approvals on Tuesday morning, December 7, for 21 new CMS approved issues for RAC review, including 110 new DRG Validations, plus medical necessity review for Renal and Urinary Tract Disorders, which would include at least […]

Physician Leases Self-disclosed in 2008 The former owner of the facility that was known as South Coast Medical Center (SCMC) in Laguna Beach, Calif., agreed to pay more than $72,000 in a civil monetary penalty (CMP) settlement concerning leases with providers. After it reported the problematic arrangements to HHS Office of Inspector General (OIG), the […]

MEDICARE IMPOSES MARKETING AND ENROLLMENT SUSPENSION ON THREE HEALTH AND DRUG SPONSORS PLAN VIOLATIONS RANGE FROM MARKETING TO RISKS TO HEALTH AND SAFETY OF MEMBERS The Centers for Medicare & Medicaid Services (CMS) today issued a notice to three Medicare health and drug plan sponsors imposing sanctions for violations of Medicare’s rules and regulations. This […]

New Demonstration Programs Support Innovation Center Goals The Centers for Medicare & Medicaid Services (CMS) today formally established the new Center for Medicare and Medicaid Innovation (Innovation Center). Created by the Affordable Care Act, the Innovation Center will examine new ways of delivering health care and paying health care providers that can save money for […]

Indeterminate Descriptions Could Include Over 200 MS-DRGs Connolly Healthcare, the Recovery Audit Contractor (RAC) for 17 states posted 35 new issues on their Approved Issues webpage and removed 4 older issues, mid-day on Wednesday, November 17, 2010. The postings continue the pattern that healthcare providers have come to expect from the 4 RACs and their […]

“Permissive” Exclusions, Even on Managers, Not Subject to Review The Office of the Inspector General (OIG) issued guidance recently, via public statements, documents and actions, explaining that it fully intends to use permissive exclusions under Sec. 1128(b)(15) of the Social Security Act, to prevent owners, officers and managing employees from working in, for or with […]

Deadline may not be extended, as before The FTC “Red Flags Rule” requires a broad range of companies to install identity theft protection programs by December 31, 2010. Red Flags are warning signals to alert a business to potential identity theft. Previously, the deadlines have been extended by the FTC, due to the volume of […]