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DoD Wants to Impose CMPs on Those Who Defraud TRICARE

Plagued by fraud and abuse targeting its TRICARE program, the U.S. Department of Defense, on May 1, issued a proposed rule that would allow it to impose civil monetary penalties (CMPs) against providers and suppliers who commit fraud and abuse against the TRICARE program. The new rule would create the “Military Health Care Fraud and […]

HHS Makes Changes to HIPAA Civil Monetary Penalty Caps

The U.S. Department of Health and Human Services (HHS) has issued a notification that it is changing the way it applies the assessment of Civil Money Penalties (CMPs) against those who violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended by the Health Information Technology for Economic and Clinical Health (“HITECH”) […]

CMS Issues Proposed Rules for Rehab and Skilled Nursing Facilities

On April 17, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that would update Medicare payment policies for Medicare Inpatient Rehabilitation Facilities (IRF). Two days later, on April 19, CMS issued another proposed rule, this one updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). Let’s start […]

April OIG Work Plan Focuses on Oversight of State, Federal Funding

Each month, the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) releases updates to its Work Plan, which outline the various projects it intends to focus on in the coming months. The April Work Plan addressed a number of items that should be of interest to a variety of […]

AHCA Postpones BA Therapy Cuts

Florida’s Agency for Health Care Administration (AHCA) has decided to postpone planned cuts to Medicaid reimbursement rates for behavioral health therapists, many of whom work with children on the autism spectrum. In March, AHCA proposed payment reductions for a variety of services as outlined below: Payments for Behavior Analysis Assessment to decrease from $385.19 to […]

Clinical Lab Industry Ripe for Fraud and Abuse

A former account rep for a toxicology testing company in Texas is the latest to be sentenced for his role in a Medicare fraud scheme that has become more common in recent years. Last month, Ivar Cantu was handed a 56-month sentence, to be followed by three years of supervised release, after pleading guilty to […]

Changes to Nursing Home Star Ratings Are Here

Beginning this month, the Centers for Medicare & Medicaid (CMS) is changing its star ratings on Nursing Home Compare and its Five-Star Quality Rating System, which allows consumers to compare quality between nursing homes. CMS says the updates “reflect more transparent and meaningful information about the quality of care that each nursing home is giving […]

Hospital Employees Fired for Celebrity Snooping

You’ve heard the saying “curiosity killed the cat,” well in the case of dozens of hospital employees, curiosity may have killed their careers. Earlier this month, Chicago’s Northwestern Memorial Hospital fired dozens of employees who allegedly accessed the medical records of actor Jussie Smollett without authorization, according to numerous published reports. The Empire actor was […]

OIG: Complimentary In-Home Care Permitted, Despite Potential Anti-Kickback Violation

A recent advisory opinion issued by the U.S. Department of Health and Human Services Office of the Inspector General has given a medical center the go-ahead to provide free in-home care to reduce re-admissions, despite a prohibition against giving patients handouts that might influence care decisions. The OIG advisory opinion is in response to a […]

Judge Rules United Behavioral Health Guidelines Led to Denial of Claims Violations

A California federal judge has issued a landmark ruling that could impact the way insurance companies cover mental health and substance use treatment. Chief Magistrate Judge Joseph Spero of the District Court for the Northern District of California ruled that United Behavioral Health (UBH) used “flawed” internal guidelines resulting in the unlawful denial of mental […]

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