Health care reform legislation increased the tools the government can use to recover money incorrectly paid to providers. The risk to providers of retaining overpayments has increased significantly.

Effective March 23, 2010, the law requires a person (including health care providers who are reimbursed under part A and Part B) who has received an overpayment from claims billed to Medicare or Medicaid to report and return the overpayment to the Secretary of HHS, the State, the intermediary, carrier, or contractor, as appropriate. In addition, the person must state the reason for the overpayment.Continue Reading Failure to Report and Return Identified Overpayment can be a False Claim

Under the Patient Protection and Affordable Care Act, all states are required to contract with recovery audit contractors (RACs) by December 31, 2010. This program is being expanded to Medicaid, as well as to Medicare Parts C and D. Federal regulations to carry out the expanded RAC program will be created by the Secretary of Health and Human Services.

RACs have been used since 2006 (following a three year demonstration project) to conduct audits of Medicare providers to determine whether an overpayment was made in Medicare Parts A and B claims. RACs typically review a small sample of claims from a health care provider for a specific review period and calculate an error rate, based on the RAC’s determination as to whether claims were improperly paid.Continue Reading Recovery Audit Contractor Program Will Be Expanded to Medicaid

On July 13, 2010, the Centers for Medicare and Medicaid Services (“CMS”) published a proposed rule that would require physicians to disclose to their patient(s), at the time of ordering a CT, MRI or PET Scan service that may be performed in the physician’s office, the name, address, telephone number and distance from the physician’s office of ten (10) competing suppliers of the CT, MRI or PET Scan service where the patient may wish to have the test performed. This proposed rule implements a provision in the Patient Protection and Affordable Case Act (the “PPACA” or “Health Care Reform Legislation”) that mandates the disclosure at the time the test is ordered.
Continue Reading CMS Issues Proposed Rule on Disclosure Requirements for Certain In-Office Imaging Services

On April 15, 2010, President Barack Obama issued a memorandum to the U.S. Department of Health and Human Services (“HHS”) calling for the initiation of rulemaking designed to ensure that Medicare and Medicaid participating hospitals respect the rights of patients to designate visitors, regardless of whether the visitors are legally related to the patient. In accordance with the Presidential memorandum, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule on Tuesday, June 22 to revise the Medicare conditions of participation for hospitals and critical access hospitals to ensure the visitation rights of all patients. Under the proposed rule, hospitals must inform patients of their visitation rights, any clinical restrictions on those rights, and their right to receive any visitors they designate. Hospitals are prohibited from restricting or denying visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity or disability. Pursuant to the proposed rule, hospitals must ensure that designated visitors have the same visitation privileges afforded immediate family members.
Continue Reading CMS Issues Proposed Rule Regarding Hospital Patient Visitation Rights

Assistant Attorney General Lanny A. Breuer of the Criminal Division of the Department of Justice (DOJ) and U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced on December 15, 2009 the expansion of Medicare Fraud Strike Force teams to Baton Rouge, Brooklyn, Tampa in the fifth, sixth and seventh phases of a targeted criminal, civil and administrative effort against individuals and health care companies that fraudulently bill the Medicare program.Continue Reading Medicare Fraud Strike Force Expands Operations into Baton Rouge, Tampa, and Brooklyn

In May, 2009, the United States Court of Appeals for the Eleventh Circuit ruled that, among other things, a Florida dermatologist’s failure to produce photographs, which were part of her medical records, in response to a grand jury subpoena constituted obstruction of justice.  The dermatologist had been convicted of health care fraud, filing false claims and obstruction of justice in the trial court.
Continue Reading Changing Medical Records Responsive to a Jury Subpoena Ruled an Obstruction of Justice In Health Care Fraud Case