February 18, 2021
By Mary Inman, Esq. and Max Voldman, Esq.
Kickbacks in the Medicare Advantage Program: $12.5 million Settlement in Whistleblower Case
The first of its kind FCA case involves Roche and Medicare Advantage insurer Humana. The recent settlement of a whistleblower case involving the government’s Medicare Advantage program might be a sign of things to come for litigation filed under the False Claims Act (FCA), including those initiated by whistleblowers. On…
By Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Medicare Advantage beneficiaries will have wider access to plan choices. With COVID-19 impacting every population, especially older and at-risk adults, payers are taking a critical look at what benefits would be an asset for the future. Opportunities exist to enhance coverage for these populations, with lots of action set for…
September 18, 2020
By Mark Spivey
CMS Issues Early Release of MA Advance Notice
The move contrasts with shorter timelines associated with the releases of the IPPS, OPPS rules. In an apparent effort to make providers’ lives a little easier, federal officials earlier this week issued Part I of the 2022 Medicare Advantage (MA) Advance Notice of proposed payment changes. “This announcement of Medicare…
September 17, 2020
By Mary Inman, Esq. and Max Voldman, Esq.
New Settlement Demonstrates New Fraud Type in Medicare Advantage program – Inflation of bids
Two payers allegedly inflated their bids. Earlier this month, two Independence Blue Cross (IBC) subsidiaries in Pennsylvania agreed to pay $2.25 million to resolve allegations that they defrauded the Medicare Advantage (MA) program and violated the False Claims Act by improperly inflating their bids. Medicare Advantage, also known as Medicare…
May 22, 2020
By Mark Spivey
CMS Continuing Telehealth Push in Announcing Changes for Part D and Medicare Advantage Beneficiaries
The changes will be applicable to some 67 million enrollees. The approximately 67 million Americans with either Medicare Advantage (MA) or Medicare Part D health plans will enjoy more benefits and options following the implementation of changes federal officials announced just prior to the start of Memorial Day weekend.…
By Marvin D Mitchell, RN, BSN, MBA
This decision applies only to those whose stay was changed to observation after inpatient admission. In a decision released on March 24, a judge of the U.S. District Court for the District of Connecticut released a memorandum of decision in the case of Alexander v. Azar, creating new appeal rights…
January 9, 2020
By Chuck Buck
CMS Releases New MOON, Important Message from Medicare, and Detailed Notice of Discharge
Same old New MOON, but potential problems appear in two of the other three new forms. All federal forms require periodic review and reapproval by the Office of Management and Budget (OMB). The approval is indicated on the form by a unique number and an expiration date. The Centers for…
By Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Medicare Advantage plans have reacted to industry criticism of their limited coverage expansion of SdoH. I expected a buzz over our recent Monitor Mondays report and RACmonitor article about the limited coverage expansion of the social determinants of health (SDoH) by Medicare Advantage (MA) plans. Actually, there have been a…
October 10, 2019
By Chuck Buck
Trump’s Executive Order Appears to Favor Medicare Advantage Plans over Medicare FFS
Physicians are sure to bristle at a perceived push toward non-physician practitioners operating more independently. EDITOR’S NOTE: President Donald Trump last Thursday signed an executive order tweaking the Medicare system during a campaign-style rally at The Villages, a Florida retirement community. In reporting on last week’s executive order signed by…
October 3, 2019
By Mark Spivey
Kaiser Health News sues CMS, HHS over denial of access to Medicare Advantage audit info
The nonprofit news service alleges the federal government violated the Freedom of Information Act by refusing to disclose documents reflecting risk adjustment validation data. Kaiser Health News (KHN) has filed a federal lawsuit against the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human…
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Adam J. KleinAllen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAmber Soucy, MSN, RNAndrew B. Wachler, Esq.Andrew B. Wachler, Esq. and Emma E. TrivaxAndrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler, Esq. and Kaitlin Nucci, Esq.Andrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTAspen AlbrightBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBenjamin Kartchner MD, CHCQM-PhyAdvBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckClark AnthonyColleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RNDaniel Zirkman, MDDavid A. McKenzie, CAEDavid Jury MD, MSDavid M. Glaser, Esq.Delilah Davis, RN, BSN, CCADenise Coleman, LPNDenise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Hu, MD and Charles Locke, MDEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEllen Parucka Walker LCSW ACSWErica E. Remer, MD, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, BSN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John Foggle, MDJohn K. Hall, MD, JD, MBA, FCLM, FRCPCJulia K. Brodt, PhDJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKaitlin Nucci Esq.Kathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMadison AllenMaggie Elehwany, JDMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Anne Hayes Hartman, Esq.Mary Inman, Esq. and Max Voldman, Esq.Matt Lambert, MDMatthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael KennedyMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDSPhillip Angello, MDRalph Wuebker, MD, MBARichard “Dick” Beckley, YNS, USN, 1966-1970Robin Sewell, CDIP, CCS, CPC, CICRonald Hirsch, MDSarah Hillegonds, Esq.Sean M. Weiss, CEMA, CMCO, CPMA, CPC-P, CMPE, CMPM, CPC-PSean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC and David Glaser, Esq.Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®Stanley Nachimson, MSStefani Daniels, MSN, RN, CMAC, ACM and Tiffany Ferguson, LMSW, ACMStefani Daniels, MSNA, ACM, CMAC
