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Common Misunderstandings About Medicare/Medicaid Fraud and Abuse

Providers are generally familiar with prohibitions against fraud and abuse in the Medicare and Medicaid Programs, including Medicaid waiver programs, and other state and federal health care programs, such as the VA and TriCare. Private insurers now often enforce the same prohibitions applicable to federal and state programs. But there are at least two common

Discharge Planners Must Stop Accepting Kickbacks and Managers Must Monitor Receipt

Case managers/discharge planners have recently come under fire from fraud enforcers for violations of the federal anti-kickback statute. This statute generally prohibits anyone from either offering to give or actually giving anything to anyone in order to induce referrals. Case managers/discharge planners who violate the anti-kickback statute may be subject to criminal prosecution, which may

Recent Fraud Enforcement Action: Lessons for Providers

According to a July 23, 2020, press release, Progenity, Inc., fraudulently overbilled Medicaid and the VA by using a billing code that misrepresented the tests performed. Fraud enforcers also claim that Progenity provided illegal kickbacks in the form of excessive fees to physicians, meals and happy hours for physicians and their staff members, and improper

Seriously Ill COVID-19 Patients at Home

In view of recent spikes in COVID-19 cases, there is continuing concern that hospitals will be overwhelmed with severely ill patients and that beds in intensive care units (ICUs) may become unavailable. Perhaps the answer is to keep as many patients as possible, even those who are seriously ill, at home.   You may have

First, Do No Harm

“First, do no harm” is the primary directive for all healthcare practitioners. Achieving this goal at this time certainly requires vigilance, both personal and professional, on the part of all practitioners. Some commentators have suggested anecdotally that healthcare practitioners may be a significant vector of transmission of the coronavirus.   In an article in The

Practical Reasons to Develop and Maintain Fraud and Abuse Compliance Programs

Providers may have heard or read about the importance of Fraud and Abuse Compliance Programs in their organizations. Despite the wealth of available information about Compliance Programs, many providers continue to express uncertainty about their value. The practical value of Compliance Programs is now clear. Providers may avoid indictment and enforcement action, including Corporate Integrity

Provider Relief Funds: Potential Enforcement Action for False Claims

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) announced a strategic plan for oversight of COVID-19 response and recovery on May 26, 2020. The Plan includes four goals: Protect people Protect funds Protect infrastructure Promote effectiveness Providers who receive funds from the Provider Relief Fund are especially

Wound Care: Legal Issues for Providers

Wound care is a risky business these days. Providers who render wound care services are at risk for: Liability for negligent wound care Violation of fraud and abuse prohibitions based on substandard wound care Liability for abandonment when wound care services are discontinued De-certification from participation in the Medicare/Medicaid Programs Disciplinary action by state licensure

Court Refuses to Intervene in Medicare Payment Suspension

The U.S. District Court for the District of Missouri decided not to require the Centers for Medicare & Medicaid Services (CMS) to make a final determination on a provider’s suspension from the Medicare Program on the basis that such decisions are solely within the discretion of CMS [Naushad v. United States Department of Health and

Marketing Hospice Services to ALFs: Preferred Provider Agreements

New research published in Health Affairs shows that utilization of hospice services among Medicare beneficiaries is greater in assisted living facilities (ALFs) than in other settings, including private homes. Hospices should, therefore, market their services intensively to ALFs.   This finding is not surprising because management at assisted living facilities (ALFs) are often committed to