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Happy 2021! I have great news to share. I’m fairly sure that everyone reading is educated about what a preliminary injunction is, and how important it can be for a healthcare provider falsely accused of fraud to lift the mandatory suspension of reimbursement. Over the holidays, a judge found that…
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Now is the time to prepare, assess time frames and provider requirements, and ensure a proper compliance plan is in place. On March 30, the Centers for Medicare & Medicaid Services (CMS) provided a temporary respite on audit activities due to the COVID-19 crisis. This was undoubtedly a welcomed break,…
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Reporting the use of PRFs will be an ongoing issue due to the fraud and abuse implications of misusing PRFs. The federal Provider Relief Fund (PRF) was created under the provisions of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was passed to address the economic harm suffered…
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OIG determines admissions to inpatient rehab not appropriate. Last week, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an audit of OSF Saint Francis Medical Center in Peoria, Ill. In this audit, the majority of the errors were once again due to admissions…
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There are COVID-19 hot spots and now there are potential covid audit hot spots. The Coronavirus Aid, Relief, and Economic Security (CARES) Act was enacted on March 27, 2020. Through the CARES Act and subsequent legislation, hundreds of billions of dollars have been allocated for healthcare providers, including under the…
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A culture of compliance is the key to success. There are no indications that audits of healthcare entities by government payers are slowing down – if anything, the ramping up of audit operations that was hinted at a short while ago has indeed materialized. Commercial payers are moving just as…
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Never ignore a request for records by the single-state agency in your state. One of the best examples that illustrates the importance of the “single state agency” involves a Medicaid fraud scheme in Illinois involving four women. It’s a real-life Bonnie and Clyde – if Bonnie and Clyde stole healthcare…
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The pandemic continues to impact Medicare reimbursement. COVID-19 continues to make news on the regulatory front with two new directives from the Centers for Medicare & Medicaid Services (CMS), centering on testing for the deadly coronavirus and formal coding edits for the Medicare Administrative Contractors (MACs) on payments with the…
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Opdivo is an immunotherapy treatment for advanced cancer. What is Opdivo? It’s a new target for Recovery Audit Contractors (RACs), specifically Performant Recovery. Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover…
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Providers forced to camouflage in mediocrity.  EDITOR’S NOTE: This the first in a series of articles that explores the use of algorithms in the auditing of medical claims. The Centers for Medicare & Medicaid Services (CMS) has pioneered the use of computer algorithms for detection of fraud. These efforts leverage technologies…