Tag: fraud and abuse

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...

Congress Enacts the Eliminating Kickbacks in Recovery Act of 2018

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Congress has enacted a new Anti-Kickback law, known as the Eliminating Kickbacks in Recovery Act of 2018 (EKRA). This legislation specifically targets arrangements involving recovery homes, clinical treatment facilities, and laboratories. Congressional Intent and Purpose The primary intent behind...

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...

The Incentive to Self Disclose False Claims Act Overpayments

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Proactive Compliance and Regulatory Oversight The Department of Justice (DOJ), in collaboration with other regulatory agencies, places a strong emphasis on the proactive monitoring of compliance by businesses. Recognizing that governmental resources alone are insufficient to uncover every instanc...

DOJs New Evaluation of Corporate Compliance Programs – The Essence of Compliance

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The Criminal Division of the United States Department of Justice (DOJ) revised its Evaluation of Corporate Compliance Programs in April 2019. Initially introduced in 2017, this document provides prosecutors with structured guidance for investigations, charging decisions, and plea negotiations. Th...

Can Overpayments Create Criminal Liability?

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We hear a lot about potential liability under the False Claims Act (FCA) for the failure to repay overpayments within 60 days of discovery. Focus on the 60-day rule has taken focus away from the potential for criminal charges for retaining known overpayments.  Section 1128B(a)(3) of the Social S...

New 2016 Work Plan Indicates Area of Compliance Focus

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OIG 2016 Work Plan Highlights Areas of Fraud and Abuse Concern Each year the Office of Inspector General puts out a work plan that indicates the priorities that it will look up at during the upcoming year. The OIG is an organization that was created to protect the integrity of the HHS program ope...

Bad Anesthesia Billing Advice Can Lead To False Claims

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Beware Of Bogus Anesthesia Billing Advice I wanted to alert anesthesia groups to what I consider to be some very bad advice that is being provided by some billing consultants.  If taken, the advice could put your group in the midst of a lawsuit with a third-party payor or even a claim of insura...

60 Day Repayment Rule and 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...