Category: Billing and Reimbursement

Using Artificial Intelligence to Detect Potential Health Care Fraud

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How AI Can Mitigate or Create Fraud and Abuse Risks in the Healthcare Industry The age of Artificial Intelligence is clearly upon us.  Unless you are living in a cave it would be impossible not to understand that it will have an enormous impact on nearly every aspect of society, including the hea...

Compliance Officer Authority and Resource Allocation

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The Department of Justice (DOJ) uses resource allocation as a key measure when evaluating the effectiveness of compliance programs. Allocating sufficient resources to the compliance function is foundational to any systematic compliance initiative and remains central as regulatory expectations evo...

Apply the 60-Day Repayment Rule to Medicaid Overpayments

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Overview of Overpayment Reporting and Repayment The Affordable Care Act (ACA) imposes specific requirements on individuals and entities that receive overpayments from designated government health programs. Under the ACA, any person who has received an overpayment from programs such as Medicare Pa...

Authentication of Verbal Orders by Other Responsible Practitioner

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Prompt Authentication of Verbal Orders ; Verbal Order Risks The failure of a physician to timely sign a verbal order can have reimbursement implications. In some cases, in some states, another responsible provider can sign a verbal order that is originally given by another practitioner. This opti...

Telemedicine Compliance Series – Licensing Issues in Telehealth

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How Telemedicine Licensing Issues Arise – Compliance for Telehealth Programs The practice of medicine is licensed and regulated at the state level.  The jurisdiction of individual states over medical licensure is broadly recognized by the courts and the federal government, including CMS.  The f...

Revision to Medicare oversight or provider based status.

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Hospital Provider Based Status Review OIG 2016 Work Plan Coverage   There’s a lot of activity in the area of provider based facilities and hospitals outpatient departments. Laws are changing to equalize reimbursement that is available between provider-based and physician office settings. Service...

Medical Director Agreement Payments May Be Source of Stark Law Compliance Concerns

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MEDICAL DIRECTOR PAYMENTS AS STARK LAW VIOLATIONS The relatively recent case serves as a reminder of the potential exposure to Stark Law liability arising from payments to medical directors.  Let me immediately clarify that not all payments to directors who perform legitimate services that are a...

60 Day Repayment Rule False Claims Act

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The 60-Day Repayment Rule and False Claims Act Providers Get Another Push Into Proactive Compliance The Patient and Program Protection Act (“PPACA”) added a number of additional tools to the government’s fraud fighting arsenal.  One of those tools is found in PPACA Section 6402 and require...

Ambulatory Surgery Center Structural and Valuation Issues

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ASC Regulatory and Structural Issues   A recent “advanced session” was provided by the American Health Lawyer’s Association covering several of the central legal issues that arise with respect to ASC ownership and structure.  The general issues covered in the webinar included:   1.A...