On September 21, 2016, the House Ways and Means Committee approved H.R. 5713, the “Sustaining Healthcare Integrity and Fair Treatment Act of 2016” or “SHIFT Act.” The primary focus of the SHIFT Act is to provide an additional delay in full implementation of the “25 Percent Rule” for long-term acute care hospitals (LTCHs). The legislation … Continue Reading
The OIG has released its Medicaid Fraud Control Units Fiscal Year 2015 Annual Report, which compiles data on investigations and prosecutions by the 50 MFCUs. According to the OIG, MFCUs attained 1,553 convictions in FY 2015, the highest in the last five years. Almost one-third of these convictions involved personal care services attendants, and 71% … Continue Reading
A number of recent Congressional hearings have focused on health policy issues, including: Senate Health, Education, Labor, and Pensions Committee hearings on laboratory testing in the era of precision medicine, and the safety of cosmetics. A House Judiciary Committee hearing on “Treating the Opioid Epidemic: The State of Competition in the Markets for Addiction Medicine.” … Continue Reading
The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have proposed amendments to the regulations governing State Medicaid Fraud Control Units (MFCUs). The proposed rule would reflect statutory changes and policies adopted since the MFCU regulations were initially issued in 1978. Among other things, the rule would incorporate statutory … Continue Reading
The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) recently issued several reports on various Medicare Part B drug reimbursement issues. In a report entitled “Medicare Part B: Data on Coupon Discounts Needed to Evaluate Methodology for Setting Drug Payment Rates,” the GAO assessed the impact of manufacturer coupon programs on … Continue Reading
The OIG has updated its guidance for providers under Corporate Integrity Agreements regarding the circumstances that might affect the independence and objectivity of independent review organizations (IROs). The updated guidance reflects 2011 revisions to Government Accountability Office (GAO) auditing standards (known as the “Yellow Book”).… Continue Reading
The Department of Health and Human Services (HHS) is increasing maximum civil monetary penalty (CMP) amounts applicable to HHS agencies and programs, in compliance with the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 (which was part of the Bipartisan Budget Act of 2015). The magnitude of the individual CMP increases varies depending … Continue Reading
CMS has announced a number of changes to its temporary Medicare enrollment moratoria for certain provider types in select geographic areas as a mechanism to address fraud, waste, and abuse. First, CMS is extending for six months and expanding statewide its current moratoria on the enrollment of new Medicare Part B nonemergency ground ambulance suppliers … Continue Reading
On June 22, 2016, the Department of Health and Human Services Office of Inspector General (“OIG”) issued a comprehensive report detailing its nationwide analysis of common characteristics in home health fraud cases. In tandem with this report, the OIG issued an Alert on improper arrangements and conduct by and among home health agencies (“HHAs”) and physicians. … Continue Reading
CMS has announced a new three-year Medicare “pre-claim review” demonstration for home health services in five states — Illinois, Florida, Texas, Michigan, and Massachusetts — with “high incidences of fraud and improper payments for these services.” The pre-claim review demonstration requires currently-mandated documentation to be furnished to the Medicare Administrative Contractor (MAC) earlier in the … Continue Reading
CMS has issued a proposed rule to make changes to the PERM and MEQC programs to align with changes to state adjudication of Medicaid and Children’s Health Insurance Program (CHIP) eligibility under the Affordable Care Act. The proposed rule also includes revisions to PERM and MEQC policies that are intended to reduce state burdens associated … Continue Reading
The HHS OIG has updated its FY 2016 Work Plan to reflect new and/or completed items since initial release of the FY 2016 Work Plan in November 2015. For instance, the mid-year update indicates that the OIG plans to conduct several new Medicare reviews, including reviews regarding:… Continue Reading
The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) have recently examined a number of Medicare and Medicaid provider screening and related program integrity issues. The OIG reports include the following:… Continue Reading
The OIG has issued its Spring 2016 Semiannual Report to Congress, which describes significant enforcement and investigative activities relating to HHS programs during the first half of FY 2016 (October 1, 2015 – March 31, 2016). The OIG reports expected recoveries of more than $2.77 billion ($554.7 million in audit receivables and about $2.22 billion … Continue Reading
Recent Congressional hearings focusing on health policy topics include the following: House Energy and Commerce Committee hearings on HHS cybersecurity responsibilities, Medicare and Medicaid program integrity, the Administration’s proposed Medicare Part B drug payment model, and patient-focused health insurance reforms. House Ways and Means Committee hearings on implementation of the Medicare Access & CHIP Reauthorization … Continue Reading
The Office of Inspector General (OIG) of the Department of Health and Human Services has issued new, non-binding “Criteria for Implementing Section 1128(b)(7) Exclusion Authority” updating the factors OIG will consider in deciding whether to exclude persons “whose continued participation in the [federal health care programs] constitutes a risk to the programs and their beneficiaries.” … Continue Reading
The OIG has released the 2016 edition of its “Compendium of Unimplemented Recommendations,” which identifies what the OIG considers to be its top 25 unimplemented recommendations in terms of HHS program savings and/or quality improvements. About one-third of the priority recommendations involve Medicare Parts A and B policies, including recommendations to adjust payment policies for … Continue Reading
The federal government won or negotiated more than $1.9 billion in judgments and settlements, and attained additional administrative impositions in health care fraud cases and proceedings in FY 2015, according to the latest HCFAC program annual report. These new efforts, together with prior year actions, resulted in a total of $2.4 billion in health fraud … Continue Reading
On March 1, 2016, CMS is publishing a proposed rule that would make a variety of changes to the Medicare, Medicaid, and CHIP provider and supplier enrollment requirements. CMS believes that the proposal would assist in ensuring that individuals and entities posing risks to federal health care programs are removed or temporarily/permanently barred from participation … Continue Reading
On February 9, 2016, the Obama Administration released its proposed fiscal year (FY) 2017 budget, which contains significant Medicare and Medicaid reimbursement and program integrity legislative proposals – including $419 billion in Medicare savings over 10 years. These proposed policy changes would require action by Congress, and Republican Congressional leaders have already voiced general opposition … Continue Reading
CMS published a notice February 2, 2016 announcing an additional 6-month extension of its current temporary Medicare enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs), subunits, and branch locations in designated metropolitan areas. The moratoria, which also apply to enrollment in Medicaid and the Children’s Health Insurance Program, apply to: New … Continue Reading
The Centers for Medicare & Medicaid Services (CMS) has issued a final rule to require Medicare prior authorization (PA) for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.” Notably, however, key policy decisions — including the items that will initially be subject … Continue Reading
On December 28, 2015, President Obama signed into law S. 2425, the Patient Access and Medicare Protection Act, which includes a number of Medicare provisions that were not included in the Consolidated Appropriations Act. Most significantly, the law: Extends the timeframe for eligible professionals and hospitals to apply for a hardship exception from meaningful use … Continue Reading
The U.S. Department of Justice (DOJ) recently reported $3.5 billion in settlements and judgments from civil cases involving fraud and false claims in FY 2015 – $1.9 billion of which came from companies and individuals in the health care industry. DOJ notes that the $1.9 billion reflects only federal recoveries; in many cases, there were … Continue Reading
