A recent False Claims Act (FCA) case sheds light on emerging trends in federal risk adjustment fraud investigations within the Affordable Care Act (ACA) insurance exchanges. These exchanges, created under the ACA, aim to provide competitive insurance options to small businesses and individuals while preventing insurers from setting premiums based on health status.
Due to concerns about insurers avoiding high-risk individuals, the ACA introduced the HHS risk adjustment model. However, this model may incentivize carriers to manipulate diagnosis codes to create the appearance of sicker insureds.
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The Centers for Medicare and Medicaid Services (“CMS”) conduct frequent audits of healthcare practices that can result in significant overpayment demands. Recently, the CMS has focused on providers who bill for injections derived from amniotic stem cells.
The core issue behind these audits is the lack of Food and Drug Administration (FDA) approval for these injections, which the CMS argues should not have been on the market. However, the situation is more complex than it appears.
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Podiatrists nationwide are receiving audit letters from Recovery Audit Contractors (RAC), who conduct Medicare audits and are incentivized to recover money for CMS. Podiatrists have always been audited on routine footcare codes, braces, and custom orthotics. However, most recently, CMS has started to focus on wound care.
In a new article by Frier Levitt attorneys Guillermo Beades and Lawrence Kobak, they discuss frequently encountered reasons for RAC audits involving wound care and how to best respond to the CMS.
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Understanding and effectively navigating CMS audit appeals process is essential for healthcare professionals, practice managers, and owners.
In a recent article, Frier Levitt attorney Guillermo Beades provides insights into the CMS audit appeals process, emphasizing the significance of meeting deadlines, how to navigate recoupments, and knowing when to seek legal counsel.
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Medicare Advantage, also known as Medicare Part C, is a program that covers over half of the country's Medicare beneficiaries. The submission of false diagnosis codes (or “upcoding”) in Medicare Advantage appears to be widespread, as a recent HHS-OIG audit revealed a 93.8% rate of improper coding for a particular Medicare Advantage Plan. The audit, coupled with a recent DOJ settlement, suggests the prevalence of upcoding and the government’s enforcement interest.
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The federal government recently reached a $22 million settlement with Martin's Point, shedding light on alleged Medicare Advantage (MA) risk adjustment upcoding practices.
To learn more about this case and Medicare Advantage risk adjustment, read article by Frier Levitt partner Jason Silberberg here.
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A recent audit report by the Department of Health and Human Services' Office of Inspector General (OIG) identified issues with psychotherapy claims that resulted in an estimated $580 million in improper Medicare payments. These findings are expected to lead to increased scrutiny of psychotherapy providers by Medicare and other payers.
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The Department of Health and Human Services (HHS) and the Drug Enforcement Administration (DEA) jointly issued a second temporary rule, extending the telemedicine flexibilities for prescribing controlled substances that were introduced during the Covid-19 pandemic. These flexibilities will remain in effect until December 31, 2024.
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Providers billing MA should closely monitor a recent lawsuit filed by Humana against CMS. The lawsuit's outcome could lead to increased audits and claw-backs by Medicare Advantage Organizations (MAOs), potentially affecting capitated provider groups and other MA providers.
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Frier Levitt’s attorneys counsel healthcare providers, including owners and investors within the healthcare industry, to meet the regulatory and contractual requirements surrounding change of ownership (“CHOW”) transactions, corporate restructuring, and similar acquisitions. With our guidance, these stakeholders have used our streamlined process to accomplish their business goals.
If you are looking to purchase or sell a healthcare practice or a pharmacy, it is important to contact an attorney who is experienced handling such transactions. The regulatory and contractual complexities involved demand seasoned guidance. Contact Frier Levitt to speak with one of our experienced healthcare and life sciences attorneys and let us navigate the intricacies of CHOW transactions for you. Your success is our priority.
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Very truly yours,
Co-Founding Partner
Frier Levitt
973.618.1660
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© 2023 Frier Levitt. All rights reserved. ATTORNEY ADVERTISING.
The contents of this newsletter and all related communications do not constitute legal advice or an attorney-client relationship. Publication contents are for general information purposes and are not intended to be a substitute for legal advice. You should seek legal advice or other professional advice in relation to any particular questions that you or your organization may have.
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