Tag Archives: Fraud and Abuse

CMS Again Extends HHA/Ambulance Enrollment Moratoria in Selected States to “Prevent and Combat Fraud, Waste, and Abuse”

The Centers for Medicare & Medicaid Services (CMS) has once again extended for six months its “temporary” moratoria on the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) enrollment of new nonemergency ground ambulance suppliers and home health agencies (HHAs) in selected states, effective July 29, 2017. The moratoria on new HHA enrollment (including new … Continue Reading

House Committees Examine Health Care Policy Issues

Recent House of Representatives committee hearings have focused on a variety of health care policy issues, including the following: Energy and Commerce Committee hearings on: the growth and oversight of the 340B drug discount program; drug and device company communications, including clinical/economic data; state efforts to address the opioid crisis; and extension of safety net … Continue Reading

CMS Finalizes Changes to Payment Error Rate Measurement (PERM) & Medicaid Eligibility Quality Control (MEQC) Programs

CMS has published a final rule that modifies PERM and MEQC regulations to align with changes to how states adjudicate Medicaid and CHIP eligibility under the Affordable Care Act (ACA). According to CMS, the policy revisions are intended to “reduce state burden, improve program integrity, and promote state accountability.” Among other things, the rule changes … Continue Reading

OIG Issues Top 25 Unimplemented Cost-Savings and Quality-Improvement Recommendations for HHS Programs

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has released the 2017 edition of its Compendium of Unimplemented Recommendations  (“Compendium”). In the Compendium, OIG identifies the top 25 unimplemented recommendations that HHS would need to prioritize in order to facilitate OIG’s recommendations on cost savings, program effectiveness, efficiency, … Continue Reading

President Trump’s Proposed FY 2018 Budget Spares Medicare, But Calls for Deep Medicaid Cuts & FDA User Fee Hikes

President Trump has released his FY 2018 budget proposal, which the Administration dubs “A New Foundation for American Greatness.”  The proposed budget – which received a generally chilly reception on Capitol Hill – offers a mixed bag for the health care industry.  On the one hand, a document summarizing the Department of Health and Human … Continue Reading

Congressional Panels Tackle FDA Reauthorization Act and Other Health Policy Issues

On May 11, 2017, the Senate on Health, Education, Labor, and Pensions (HELP) Committee approved S 934, a bill extend Food and Drug Administration user-fee programs for prescription drugs, medical devices, generic drugs, and biosimilar biological products. The legislation also includes various policy changes, including provisions intended to improve the medical device inspection process and … Continue Reading

GAO: CMS, MACs Should Bolster Provider Education to Cut Improper Medicare Payments

In 2016, an estimated $41.1 billion in improper Medicare fee-for-services payments were made to providers. The Centers for Medicare & Medicaid Services (CMS) believes that provider education plays an important role in ensuring payments are made properly; CMS has delegated authority for provider education to the Medicare Administrative Contractors (MACs). In a recent report, the Government … Continue Reading

GAO Encourages More CMS Collaboration with States on Medicaid Program Integrity Efforts

The GAO has had ongoing concerns about the integrity of the Medicaid program due to its size, diversity, and recent rapid growth as a result of the Affordable Care Act. It is the second largest health insurance program in the U.S. based on expenditures ($576 billion combined federal and state spending projected for 2016).  At the … Continue Reading

OIG Tallies Medicaid Fraud Control Unit Achievements in FY 2016

The OIG has released national and state-by-state data quantifying State Medicaid Fraud Control Unit (MFCUs) accomplishments in fiscal year 2016. During this period MFCUs were credited with a total of: 1,721 indictments (1,249 involving fraud and 472 involving abuse or neglect); 1,564 convictions (1,160 involving fraud and 404 involving abuse or neglect); 998 civil settlements … Continue Reading

Medicare & Medicaid Remain Vulnerable to Fraud and Abuse, GAO Warns

The Government Accountability Office (GAO) is out with the latest installment of its “High-Risk Series,” which identifies federal programs “that are especially vulnerable to waste, fraud, abuse, and mismanagement, or that need transformative change.” Once again, GAO flags Medicare and Medicaid as high-risk programs. With regard to Medicare, GAO notes that while Congress, HHS, and … Continue Reading

Reed Smith Client Alert: OIG Finalizes Expanded Exclusion Authorities under ACA

The Office of Inspector General (OIG) of the Department of Health and Human Services has issued a final rule implementing its statutory authority under the Affordable Care Act (ACA) to expand the exclusion regulations applicable to persons or entities receiving funds, directly or indirectly, from federal health care programs. Specifically, the final rule expands OIG’s … Continue Reading

Regulatory Freeze Notwithstanding, Trump Administration Increases Health Fraud CMPs

The Department of Health and Human Services (HHS) is once again applying an inflation increase to maximum civil monetary penalty (CMP) amounts for HHS agencies and programs – less than five months after the last inflation hike and notwithstanding the Trump Administration’s recently-announced regulatory freeze.  Specifically, in a final rule to be published on February … Continue Reading

DOJ/OIG Update on FY 2016 Health Care Fraud and Abuse Control (HCFAC) Program Recoveries

Federal health fraud recoveries for FY 2016 totaled $3.3 billion, according to the latest HCFAC program annual report.  The HCFAC program is credited with more than $31.0 billion in Medicare Trust Funds recoveries since it began in 1997. With regard to criminal fraud, the Department of Justice (DOJ) opened 975 new criminal health care fraud … Continue Reading

OIG Finalizes Expanded Exclusion Authorities under ACA

On January 12, 2017, the Office of Inspector General (“OIG”) of the Department of Health and Human Services issued a final rule to expand the exclusion regulations applicable to persons or entities receiving funds, directly or indirectly, from federal health care programs (“Final Rule”).  The Final Rule, which implements Affordable Care Act authority, was issued with an … Continue Reading

CMS Again Extends HHA/Ambulance Enrollment Moratoria in Selected States

The Centers for Medicare & Medicaid Services (CMS) is extending for six months its current moratoria on the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) enrollment of new nonemergency ground ambulance suppliers and home health agencies (HHAs) in selected states, effective January 27, 2017.  The temporary moratoria on new HHA enrollment (including new subunits … Continue Reading

OIG Issues Annual Solicitation of Suggestions for New Fraud Alerts, Anti-Kickback Safe Harbors

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) is inviting public recommendations for new or modified safe harbor provisions under the federal anti-kickback statute.  The OIG also invites suggestions for new OIG Special Fraud Alerts to provide guidance to health care providers regarding “practices OIG finds potentially fraudulent … Continue Reading

OIG Semiannual Report Highlights FY 2016 Fraud Recoveries, Enforcement Actions

The HHS Office of Inspector General’s (OIG) latest Semiannual Report to Congress highlights top audits, investigations, and enforcement activities for the period of April 1 to September 30, 2016 and summarizes overall accomplishments for fiscal year (FY) 2016. Notably, the OIG reports: Expected FY 2016 recoveries will exceed $5.66 billion, including nearly $1.2 billion in audit … Continue Reading

OIG Issues CMP, Anti-kickback Safe Harbor Final Rules

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has published a final rule amending the safe harbors to the Anti-Kickback Statute (AKS) and the Civil Monetary Penalty (CMP) rules to protect certain payment practices and business arrangements from criminal prosecution or civil sanctions under the AKS (Final Rule). … Continue Reading

Medicare, Medicaid Payment Policies, Fraud Authorities Enacted as Part of 21st Century Cures Act

Included in the 21st Century Cures Act are numerous changes to Medicare and Medicaid policies, including provisions with significant reimbursement impacts for certain types of Medicare providers and suppliers, along with changes intended to reduce the regulatory and administrative burdens associated with the use of electronic health records.  Furthermore, the law once again expands the … Continue Reading

Looking Ahead to a Trump Administration: Health Care and Life Sciences Industry Perspectives

Observers are digesting what the Trump Administration will mean for the health care and life sciences industry.  Forecasting is more challenging for this incoming Administration than most given the relatively sparse policy details released during the campaign and the lack of a government service record to examine for clues.  Today President-elect Trump’s transition team released … Continue Reading
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