(December 17, 2018): Texas Medicaid Exclusions will prevent the Texas Medicaid Program from paying for any item or service furnished directly or indirectly by individuals or entities that have been excluded from a State or Federal health care program. This results in a broad “Payment Prohibition” that is enforced by the Texas Health and Human… more>>
(July 16, 2018): Perhaps the most severe administrative sanction available under the Social Security Act stems from the authority of the Secretary for the Department of Health and Human Services (HHS) to exclude individuals and entities from participating in Federal and State health benefits programs.[1] The Secretary has delegated[2] this authority to the HHS, Office… more>>
(January 12, 2018): The Medicare and Medicaid programs are both essential, yet costly health benefit programs sponsored in whole or in part by the Federal government. With Medicare and Medicaid costing $686 and $368 billion each year, respectively, the government has dedicated experienced investigators, auditors and prosecutors to ferret out incidents of health care fraud and… more>>
(January 8, 2018): Most physicians will progress through their entire career without ever having to respond to a complaint or investigation by their State Medical Board. Unfortunately, that isn’t always the case. An average of 4,309 physicians are disciplined each year by state licensure boards around the country.[1] A recent case aptly illustrates how a… more>>
Year in Review OIG Podcast Earlier this week, the Office of Inspector General released its “Year in Review” OIG Podcast highlighting the OIG’s major accomplishments for 2017. The OIG podcast reported 881 criminal actions, 826 civil actions and over $4 billion in recoveries. OIG also excluded 3,244 from participating in federal health care programs during… more>>
Is Your Practice Being Audited by a ZPIC? Did You Know it Can Lead to an OIG Exclusion?Zone Program Integrity Contractors (ZPICs) are among the most aggressive program integrity entities employed by the Centers for Medicare and Medicaid Services (CMS). As most healthcare providers are aware, ZPICs regularly place physician practices on prepayment review and… more>>
By Robert LilesHave you implemented the new “ Advance Beneficiary Notice of Noncoverage ” (ABN), required by the Centers for Medicare and Medicaid Services (CMS)? As CMS has noted, although the latest version of the form (ABN Form CMS-R-131) does not include any substantive changes, in accordance with Section 504 of the Rehabilitation Act of 1973, the… more>>
By Catalina Jandorf The Office of the Inspector General (OIG) has recently entered into a number of exclusion case settlements tied to skilled nursing facilities and hospitals. Additionally, there have been several recent investigations targeted towards physician practices. A rising number of these cases with sizable settlement recoveries highlight an emerging trend to be on the lookout… more>>
Exclusion News (May 22, 2017): By Paul WeidenfeldHealth Care Fraud will continue to be a high priority of the Department of Justice Kenneth Blanco, the Acting Head of the Criminal Division. Describing health care fraud as “egregious,” “despicable” and driven by “greed” – Mr. Blanco, told the iABA Health Care Fraud Institute last week. went… more>>
The recently issued Resource Guide for Measuring Compliance Program Effectiveness, reconfigures the traditional formulation of the “Seven Elements of an Effective Compliance Program by making the “Screening and Evaluation of Employees, Physicians, Vendors and other Agents” an element unto itself – or the new “Seventh Element of Compliance!” The Resource Guide, a product of roundtable discussions… more>>