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Category Archives: Department of Health and Human Services

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Release of the 2015 OIG Work Plan

Posted in Compliance, Department of Health and Human Services, Electronic Health Records, False Claims Act, Fraud and Abuse, Regulatory Compliance

Happy Halloween!  In addition to costumes and candy, October 31 saw the release of the 2015 Work Plan by the Office of Inspector General for Health and Human Services.  Always a lengthy document, the Work Plan can indicate areas that providers and suppliers want to monitor closely, as they are areas receiving attention from the government.  In… Continue Reading

CMS Finalizes Medicare Part C and Part D Program Changes for Contract Year 2015: Moderate Deviations from Proposed Rule

Posted in Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Insurance, Managed Care, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, Pharmaceutical, PPACA, Publications

On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare… Continue Reading

CMS Issues Medicare and Medicaid Final Rule: Significant Changes to Conditions of Participation

Posted in Compliance, Department of Health and Human Services, Governance/Management, Hospitals, Physician Practice, Publications, Regulatory Compliance

On Wednesday, the Centers for Medicare and Medicaid Services (“CMS”) issued a second round of long-awaited red tape reduction initiatives aimed at ameliorating overly burdensome provider regulations.  The changes, memorialized within a Final Rule scheduled for publication on May 12, 2014 (available for review here: http://federalregister.gov/a/2014-10687) (“Unpublished Final Rule”)  include significant easing of Conditions of… Continue Reading

Is Your Name on the List?

Posted in Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, Physician Practice

Given the 880,000 names of physicians released by Medicare Wednesday, physicians who treat Medicare patients can expect their names to be on the list.  The list, searchable here, contains the name of the provider, the specialty area, the city, county and state as well as the total payments made to the provider by Medicare for… Continue Reading

CMS Adds to the Growing Guidance on Third Party Premium Payments

Posted in Department of Health and Human Services, Hospitals, Insurance, Payer/Insurance Reform, Payment Methodologies, PPACA

On February 7, 2014, the Centers for Medicare and Medicaid Services (CMS) issued a memorandum that adds to the growing library of federal guidance on the permissibility of and limitations for health care providers and other entities paying the premiums of patients covered by qualified health plans (QHPs) in the health insurance exchanges or marketplaces. … Continue Reading

Is CMS Prepared for Evolving Medical Records Technology?

Posted in Compliance, Department of Health and Human Services, Electronic Health Records, Fraud and Abuse, Regulatory Compliance, Technology

Health care fraud accounts for billions of the US health expenditure each year. This week HHS published a study addressing possible deficiencies in CMS’ capability to address fraud vulnerabilities and ensure the integrity of electronic health records (“EHR”) systems which CMS and its contractors use to pay Medicare claims. Concerns about whether CMS’ oversight and… Continue Reading

CMS Ushers in the New Year with Medicare Part C and Part D Proposed Rules: HHS Hopes to Save $1.3 Billion

Posted in Compliance, Department of Health and Human Services, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, PPACA, Regulatory Compliance

On January 10, 2014, CMS will publish the proposed rule titled Medicare Program: Contract Year 2015 and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (the “Proposed Rule”).  The Proposed Rule propositions extensive reforms to the Medicare Advantage (“Part C”) and Medicare Prescription Drug Benefit Program (“Part D”), partly through… Continue Reading

CMS and OIG Ring in the New Year with Final Rules on EHR Donations

Posted in Department of Health and Human Services, Electronic Health Records, False Claims Act, Fraud and Abuse, Hospitals, Mergers and Acquisitions, Regulatory Compliance, Technology

On December 27, 2013, the Centers for Medicare and Medicaid Services (“CMS”) and the Office of Inspector General of the Department of Health and Human Services (“OIG”) published final rules (“Final Rules”) regarding the electronic health records (“EHR”) donations Stark Law Exception (42 C.F.R. 411.357(w)) and Anti-Kickback Statute Safe Harbor (“AKS Safe Harbor”) (42 C.F.R…. Continue Reading

OIG Okays a Premium Assistance Program

Posted in Community Benefit, Compliance, Department of Health and Human Services, Fraud and Abuse

Recently, many stakeholders in the healthcare industry have expressed interest in implementing programs that provide funding to help patients with insurance premium payments.  Until last week, it was unclear whether any type of premium assistance programs would be permissible under federal law.  Finally, in Office of Inspector General (OIG) Advisory Opinion 13-19 posted on December… Continue Reading

Data Security: Pay IT Now or Pay Out Later

Posted in Compliance, Department of Health and Human Services, Electronic Health Records, Events, Technology

The price of compliance may be high, but the price of non-compliance is even higher. Based on its recent $3 million data breach settlement, AvMed, and many other entities that have experienced data breach litigation, would likely agree that paying for security upgrades now, is far superior to paying for data breaches later. In 2009,… Continue Reading

CMS Strengthens Policies to Encourage Automatic Assignment of Medicare Provider Agreements

Posted in Department of Health and Human Services, Mergers and Acquisitions

In a policy memo published September 6, 2013, the Centers for Medicare & Medicaid Services (“CMS”) encouraged new owners of Medicare providers and institutional suppliers (“providers”) to accept automatic assignment of the seller’s Medicare Provider Agreement (“Agreement”) and CMS Certification Number (“CCN”).  The overall goal appears to be to encourage automatic assignment in Change of… Continue Reading

HHS Releases “Rate Review” Impact Data: Policyholders Save $1.2 Billion Nationwide

Posted in Accountable Care Organizations, Department of Health and Human Services, Hospitals, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, PPACA

Last Thursday, September 12, 2013, the Department of Health and Human Services (“HHS”) reported that the rate review provisions (the “Rate Review Provisions”) of the Affordable Care Act (“ACA”) saved an estimated $1.2 billion on health insurance premiums in 2012 for 6.8 million policyholders.  The Rate Review Provisions are intended to increase transparency behind premium… Continue Reading

CMS Pledges to Reassess All Critical Access Hospitals’ Certification

Posted in Compliance, Department of Health and Human Services, Hospitals, Payment Methodologies

In response to a recently released Office of Inspector General (“OIG”) report that concluded CMS is overpaying many Critical Access Hospitals (CAHs), CMS pledged to reassess all CAHs’ certification.  The report asserts that CMS could realize substantial savings by decertifying non-compliant CAHs because nearly two-thirds of CAHs would not meet the location requirements if required… Continue Reading

Proposed Rules Issued Extending Protections of Electronic Health Record Donations

Posted in Accountable Care Organizations, Department of Health and Human Services, Electronic Health Records, Fraud and Abuse, Hospitals, Physician Practice, Regulatory Compliance

Proposed Rules Issued Extending Protections of Electronic Health Record Donations On April 10, 2013, the Department of Health and Human Services (DHHS), Office of Inspector General (OIG) and the DHHS, Centers for Medicare & Medicaid Services (CMS) each issued a proposed rule relating to the donation of interoperable electronic health records software or information technology… Continue Reading

OIG Issues Special Fraud Alert: Physician-Owned Distributorships (PODs)

Posted in Department of Health and Human Services, Fraud and Abuse, Physician Practice

OIG Issues Special Fraud Alert: Physician-Owned Distributorships (PODs) On March 26, 2013 the Department of Health and Human Services, Office of Inspector General (OIG) issued a Special Fraud Alert: Physician-Owned Entities (Alert).  The Alert focuses on the specific attributes and practices of “physician-owned entities that derive revenue from selling, or arranging for the sale of,… Continue Reading

Full Medicaid Expansion Required for States to See Full Federal Funding

Posted in Department of Health and Human Services, PPACA

Yesterday, the federal government announced that the federal government will not provide 100% funding for states that do not participate in the full Medicaid expansion contained in PPACA, as described by the Washington Post.  Partial expansions will be permitted but will only receive matching federal money at the existing rate, at least for 2014-2017. As we… Continue Reading

HHS Guidance for De-Identification of PHI Under the HITECH Act

Posted in Department of Health and Human Services

As required by the HITECH Act, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) has issued guidance on two methods for de-identifying protected health information (PHI) under the Health Insurance portability and Accountability Act of 1996 (HIPAA) privacy rule.[1]  “This guidance is intended to assist covered entities to understand… Continue Reading

OIG’s Continuing and New Reviews of the Medicaid Program: Managed Care

Posted in Department of Health and Human Services

As part of its Work Plan for Fiscal Year 2013, the Office of Inspector General (“OIG”) plans to focus on the following current and new issues in the Medicaid program: prescription drugs; home, community, and personal care services; equipment and supplies; state management and oversight; the Children’s Health Insurance Program; Medicaid data systems, controls, and… Continue Reading

Another Extension for States to Decide About Insurance Exchanges

Posted in Department of Health and Human Services, Payer/Insurance Reform, PPACA

For the second time in a week, the federal government has extended deadlines relating to state insurance exchanges.  Today was originally the deadline for each state to submit an application to the federal government if the state would be running its own insurance exchange.  For any state that does not set up its own exchange, the federal government… Continue Reading

Massachusetts provider settles HIPAA case for $1.5 million

Posted in Department of Health and Human Services, Fraud and Abuse

On September 17, 2012, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced that the Massachusetts Eye and Ear Infirmary and Massachusetts Eye and Ear Associates Inc. (collectively referred to as “MEEI”) agreed to pay $1.5 million to settle potential violations of the Health Insurance Portability and Accountability Act… Continue Reading

U.S. Supreme Court Rules the Individual Mandate Is Constitutional and Limits Medicaid Expansion Laws

Posted in Department of Health and Human Services, PPACA

The decision we’ve all been waiting for is in — the U.S. Supreme Court has ruled that the statute commonly known as the individual insurance mandate (everyone must have minimum health insurance coverage or pay a penalty) is constitutional under Congress’ taxing power.  Because the individual mandate was upheld, the rest of the Affordable Care Act (“PPACA”) has also survived.  The… Continue Reading

Make Your Voice Heard on the Direction of EHR MU Stage 3 Criteria

Posted in Department of Health and Human Services

Two workgroups that advise the Office of the National Coordinator for Health Information Technology seek input to identify ways in which Meaningful Use Stage 3 may advance the consistent delivery of high quality care in diverse care settings.  The committees recently hosted a meeting of experts from health care delivery organizations, quality improvement organizations, industry,… Continue Reading

OIG Solicits Comments Regarding Revision to Self-Disclosure Protocol

Posted in Department of Health and Human Services, Fraud and Abuse

On June 18, the OIG published notice in the Federal Register advising that it is now soliciting information and recommendations for revising its provider self-disclosure protocol. [https://www.federalregister.gov/articles/2012/06/18/2012-14585/solicitation-of-information-and-recommendations-for-revising-oigs-provider-self-disclosure-protocol#p-13] The OIG’s self-disclosure protocol is a mechanism whereby providers may voluntarily disclose self-discovered evidence of potential violations of the Anti-Kickback Statute.  Providers utilizing the protocol must disclose a… Continue Reading

GAO Recommends Changing Medicaid Audit Program Due To Poor Results

Posted in Department of Health and Human Services, Fraud and Abuse

It appears that the National Medicaid Audit Program hasn’t been worth the money it cost to run.  According to published testimony released by the Government Accountability Office (GAO) today, only 4% of the 1,550 audits, though, resulted in refunds to the government of approximately $7.4 million.  More than two-thirds of the audits found no overpayments.  The remaining 27%… Continue Reading