Backlog Backlash: HHS Says Clearing Medicare Backlog Not Possible

Just two months after a federal judge told the Department of Health and Human Services (HHS) to clear through a huge backlog of Medicare claims appeals comes word from the agency that not only will it not be able to comply, but that the backlog will actually grow by the time it’s supposed to have […]

Long-awaited rule for Quality Payment Program unveiled

The U.S. Department of Health and Human Services recently issued its long-awaited final rule on the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA). The new rule is designed to move the healthcare industry away from a volume-based system to value-based care models. (Read: see fewer patients, provide better quality […]

Blame it on Inflation: Civil Monetary Penalties Increase

The U.S. Department of Health and Human Services (HHS) has published an interim final rule that adjusts for inflation the maximum civil monetary penalties (CMP) that HHS agencies are authorized to assess or enforce. The changes became effective Sept. 6, and are applicable only to civil penalties assessed after Aug. 1, 2016, whose associated violations […]

Will proposed rule change clear Medicare appeal claims logjam?

The Department of Health and Human Services late last month took a small step toward easing a very big problem. The agency issued a proposed rule designed to help reduce the backlog of more than 700,000 Medicare claims stuck in the appeals process. The proposed changes to the Medicare appeals process would “streamline administrative processes, […]

Report: HHS OIG fraud recoveries on the rise

The Department of Health and Human Services Office of the Inspector General recently released its semi-annual Report to Congress outlining its anti-fraud activities. The report highlights OIG’s accomplishments for the six-month period ending March 31, 2016. The agency noted that during that period it reported expected recoveries of more than $2.77 billion consisting of nearly […]

Audit: HHS fails to accurately report and prevent improper payments

A recent audit of the Department of Health and Human Services (HHS) to determine if the agency is in compliance with the reporting standards required under the Improper Payments Information Act (IPIA) of 2002 found an ongoing failure by the agency to accurately report and prevent improper payments. The audit, conducted by Ernst & Young […]

States’ failure to implement NCCI edits cost Medicaid program billions annually

Improper payments to healthcare providers cost the Medicaid program approximately $17.5 billion in fiscal year 2014, according to a new report from the HHS Office of the Inspector General. The reason: States’ failure to fully implement or properly use Medicaid National Correct Coding Initiative (NCCI) edits. The purpose of the NCCI edits is to prevent […]

Government recovers $1.9 billion in healthcare fraud judgments and settlements in FY 2015

A newly released report by the Health Care Fraud and Abuse Control Program (HCFAC) shows that the federal government won or negotiated more than $1.9 billion in healthcare fraud judgments and settlements in fiscal year 2015. As a result of these efforts, as well as those of preceding years, in fiscal year 2015, approximately $2.4 […]

GAO Report: HHS Lacks Adequate Healthcare Workforce Planning

The Department of Health and Human Services (HHS), which engages in planning for the 72 healthcare workforce programs administered by its agencies, lacks comprehensive planning and oversight to ensure that these efforts meet national healthcare workforce needs, according to a new report from the U.S. Government Accountability Office. These programs send HHS funding to institutions […]

How data mining is uncovering healthcare fraud

What does your data say about your healthcare practice? Does it show that you bill considerably more than your colleagues for certain types of procedures? What about your facility? Is it performing more of a particular procedure than nearby competitors? These days, healthcare fraud investigators increasingly rely on data to root out healthcare fraud. They […]

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