Citing an interest in improving its processes and eliminating unnecessary requirements, CMS is hosting July 13, 2018 “Provider Compliance Focus Group” meeting regarding Medicare fee-for-service compliance topics, including medical review, targeted probe and educate, and Recovery Audit Contractors. CMS states that it wants “to ensure claims are paid appropriately and preserve the Medicare Trust Fund
Fraud and Abuse
Roundup of Recent Congressional Hearings, Markups on Health Policy Issues
Congressional committees have held numerous hearings and markups in recent weeks on health policy topics, including several hearings focused on health care costs. Highlights include the following:
Continue Reading Roundup of Recent Congressional Hearings, Markups on Health Policy Issues
OIG, DOJ Announce FY 2017 Health Care Fraud and Abuse Control (HCFAC) Program Recoveries
Federal health fraud recoveries for FY 2017 totaled $2.6 billion, according to the latest HCFAC program annual report, compared to $3.3 billion in FY 2016. The Department of Justice (DOJ) opened 967 new criminal health care fraud investigations in FY 2017, filed criminal charges in 439 cases involving 720 defendants, obtained convictions of 639…
Congressional Hearings Focus on Health Care Innovation, Medicaid Fraud, Health Policy Legislation – But Spotlight Remains on Opioids
Congressional committees with jurisdiction over health care legislation continue to focus on the opioid crisis:
- The Energy and Commerce held a hearing on “Combating the Opioid Crisis: Improving the Ability of Medicare and Medicaid to Provide Care for Patients” and a roundtable discussion on “Personal Stories from the Opioid Crisis.”
- The House Oversight Healthcare Subcommittee examined “Local Responses and Resources to Curtail the Opioid Epidemic.”
- A Senate Judiciary Committee hearing focused on “Defeating Fentanyl: Addressing the Deadliest Drugs Fueling the Opioid Crisis.”
- The Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing on S.2680, the Opioid Crisis Response Act of 2018; the Committee is scheduled to vote on the legislation April 24.
- The House Ways and Means Trade Subcommittee will hold a hearing April 25 on “The Opioid Crisis: Stopping the Flow of Synthetic Opioids in the International Mail System.”
In other policy areas:
Continue Reading Congressional Hearings Focus on Health Care Innovation, Medicaid Fraud, Health Policy Legislation – But Spotlight Remains on Opioids
Trump Administration’s Proposed FY 2019 Budget Targets Medicare, Medicaid for Savings, Seeks (Again) to Repeal/Replace ACA
The Trump Administration has released its fiscal year (FY) 2019 budget proposal, which includes extensive health policy provisions. While most of the President’s policy proposals for Department of Health and Human Services (HHS) programs would require Congressional approval, others are characterized as administrative proposals that presumably would not involve Congress.
Continue Reading Trump Administration’s Proposed FY 2019 Budget Targets Medicare, Medicaid for Savings, Seeks (Again) to Repeal/Replace ACA
VA and HHS Team Together to Combat Health Care Fraud, Waste, and Abuse
The Department of Veterans Affairs (VA) and the Centers for Medicare & Medicaid Services (CMS) have announced a partnership to leverage CMS’s program integrity tools to detect and prevent fraud within VA programs. The collaboration will focus on applying state-of-the-art data analytics tools and best practices identified by CMS to VA claims payment processes. In …
DOJ Recouped $2.4 billion in Health Care Industry False Claims Act Settlements in FY 2017
The Department of Justice (DOJ) obtained $3.7 billion in False Claims Act (FCA) settlements and judgments in fiscal year (FY) 2017, with $2.4 billion coming from health care industry cases. The $2.4 billion amount includes only federal recoveries; additional funds were recovered for state Medicaid programs. The largest health care industry recoveries in FY 2017–…
OIG Highlights Recent Audit, Investigation, and Enforcement Accomplishments
The Office of Inspector General (OIG) of the Department of Health and Human Services has released its semiannual report for the period of April 1, 2017, through September 30, 2017. The report also includes aggregated data for all of fiscal year (FY) 2017. For instance, during FY 2017, the OIG achieved:
- $4.13 billion in expected
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OIG: Medicare Program Integrity at the Top of HHS Management Challenges
The OIG’s latest compilation of top HHS management and performance challenges flags vulnerabilities in key HHS health and social services programs, including includes the following:
- Ensuring Program Integrity in Medicare (addressing improper payments, fraud, payment policies, health care reforms, and health information technology).
- Ensuring Program Integrity in Medicaid (including compliance with fiscal controls, fraud prevention,
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DOJ Settles Second 60-Day Overpayment Case, Highlights Broader Reach of the FCA’s Reverse False Claims Provision
A recent False Claims Act (“FCA”) settlement involving an allegedly overpaid Florida medical practice reaffirms the interplay between the 60-Day Overpayment Statute and the FCA, but also highlights the importance for all providers and suppliers to report and return overpayments, regardless of the source of federal funds.
According to the Department of Justice (“DOJ”), First Coast Cardiovascular Institute (“FCCI”) allowed credit balances from various federal health care programs to accrue despite multiple internal warnings that the balances should be paid back. DOJ alleged that FCCI’s failure to return those credit balances within 60 days violated the FCA. DOJ’s comments are notable, however, because the credit balances not only involved Medicare and Medicaid, but also TRICARE and the Department of Veterans Affairs, both of which are outside the scope of the 60-Day Overpayment Statute. DOJ and FCCI resolved the alleged $175,000 in unreturned overpayments for a $448,821.58 price.
Continue Reading DOJ Settles Second 60-Day Overpayment Case, Highlights Broader Reach of the FCA’s Reverse False Claims Provision
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…
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
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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…
First Look at OIG’s FY 2017 Fraud Recoveries/Enforcement Activities
The HHS Office of Inspector General (OIG) expects its investigative recoveries during the first half of fiscal year (FY) 2017 to top $2.04 billion – which is down from $2.77 billion for the first half of FY 2016. During this period, the OIG reports 468 criminal actions against individuals or entities that engaged in crimes…
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, and quality improvements in HHS programs. More than half of these top 25 recommendations focus on programs regulated by the Centers for Medicare & Medicaid Services (CMS), while others focus on programs regulated by other HHS agencies and states. The top priorities identified by the OIG in the Compendium include recommendations broadly aimed at:
- Protecting beneficiaries from drug abuse, including opioid abuse
- Ensuring program integrity, quality of care, and safety in programs that serve children
- Reducing Medicaid fraud and patient harm, including in the delivery of personal care services
- Reducing home health fraud
- Promoting economy and efficiency in drug pricing and reimbursement
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…
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 modify the regulation of hearing aids, among other things. The bill now moves to the full Senate. Previously, the HELP Committee approved: S 652, to reauthorize a program for early detection, diagnosis, and treatment regarding deaf and hard-of-hearing newborns, infants, and young children; S 849, to support programs for mosquito-borne and other vector-borne disease surveillance and control; S 916, to amend the Controlled Substances Act with regard to the provision of emergency medical services; and S 920, to establish a National Clinical Care Commission.
The House Energy and Commerce Committee also held a hearing regarding improving the regulation of medical technologies. The hearing focused on the following bipartisan bills: HR 1652, the Over-the-Counter Hearing Aid Act of 2017; HR 2009, the Fostering Innovation in Medical Imaging Act; HR 2118, the Medical Device Servicing and Accountability Act, and HR 1736, to amend the Federal Food, Drug, and Cosmetic Act to improve the process for inspections of device. The panel held a separate hearing on “Combating Waste Fraud and Abuse in Medicaid Personal Care Services Program.”
In addition, the following hearings and markups are scheduled next week:
Continue Reading Congressional Panels Tackle FDA Reauthorization Act and Other Health Policy Issues
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,…
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…
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
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