Medicare Rules

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OIG WORKPLAN 2016

The Office of the Inspector General (OIG) is responsible for protecting the integrity of the programs in Health and Human Services against fraud, waste and abuse as well as recommending improvements to the system that would promote efficiency and efficacy within the limits of the health care laws.   Although OIG oversight includes programs such as

Overview of a Corporate Integrity Agreement (CIA)

Health care fraud recoveries for fiscal years 2009- 2014 exceeded previous records with five straight years of more than $2 billion in annual recovery from cases involving fraud and false claims against federal health care programs such as Medicare and Medicaid.  Most healthcare providers are aware of significant civil liability due to recent enforcement. However,

Are You Prepared for the HIPAA Phase 2 Audits?

After reviewing the HIPAA Privacy case investigations from 2009-2011, the Office of the Inspector General sent a strong message to the Office of Civil Rights in regard to the administration and enforcement of the HIPAA Privacy Rule. The OIG recommendation is clear in the September 2015 executive summary, “OCR Should Strengthen Its Oversight of Covered

Billing Care Plan Oversight Risks

Care Plan Oversight describes the physician or other healthcare professional’s supervision of patients in hospice, nursing facilities or those receiving care through home health agencies. CPO reimbursement covers initial certification, any re-certifications and care plan supervision. However, only physicians can bill for initial certification and re-certification and only one physician can bill per month. The

Are You Aware of the Whistleblower Provisions of the False Claim Act ?

The whistleblower provisions of the False Claims Act have lead to several newsworthy cases in recent years. Just a few days ago, the Justice Department announced that KMART Corporation (Kmart) will pay $1.4 Million to resolve False Claims Act allegations for knowingly providing coupons to Medicare beneficiaries to waive or reduce co-pays for purchasing more

Complying with Stark Law: Can you bill Medicare when treating your family members?

The treatment of family members falls under General Exclusions from Coverage under Medicare. No payment will be made for items or services for a family member when the charge is from an immediately related provider, any of their associates or their professional corporations. As part of Stark I in 1989, self-referrals for clinical laboratory services

Are you a Meaningful User of the Future?

Since the Electronic Health Records (EHR) incentive program known as Meaningful Use began in 2011, the healthcare community has felt its impact and attempted to meet the increasing obligations. A new language has been created with an alphabet soup of acronyms. Physicians voice concerns that complying with Meaningful Use competes with attention on patients and

Do Any of Your Medicare Patients Meet the Newly Approved Lung Cancer Screening Requirements With Low Dose Computed Tomography (LDCT)?

Lung cancer is the leading cause of cancer deaths in the United States and third in overall cancer incidence according to 2013 National Cancer Institute statistics.  Fortunately, newly approved preventive service for annual lung cancer screening is available for Medicare beneficiaries meeting certain eligibility criteria. This increased availability and accessibility to screening should ultimately affect

Are You Familiar With the New CMS Payment Model?

The new CMS payment model ties reimbursement to value instead of volume. The focus is on developing a payment method based on quality and improvement of the delivery of care. The increasing ability to share information amongst providers, consumers and others, necessitates the dual function of “best possible” decision making and maintaining patient privacy. HHS

CMS Just Announced New Provider Enrollment Provisions

As of December 3, 2014, new safeguards have been added to the CMS provider enrollment policies. CMS continues to focus on prevention of Medicare fraud, waste and abuse as part of their comprehensive program integrity plan. Reportedly, 25,000 providers have already been excluded from participation and may no longer be able to re-enroll. Use of