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Waste and Fraud

April 30, 2020 | Daily News

A federal appeals court should revive a controversial overpayment rule in Medicare Advantage because, without the rule in place, CMS has limited ability to stop MA plans from engaging in one-sided medical reviews that artificially inflate their payments, the agency says in a recent legal brief.

April 01, 2020 | Daily News

The HHS Office of Inspector General is on the lookout for fraudsters during the COVID-19 outbreak but will make accommodations for providers who can’t meet deadlines because of the pandemic.

April 01, 2020 | Daily News

Anthem Inc. fraudulently overcharged CMS by millions of dollars in Medicare Advantage payments by failing to correct inaccurate diagnosis data, federal prosecutors allege in a lawsuit against the company.

March 23, 2020 | Daily News

The HHS Office of Inspector General warned Monday (March 23) that scam artists are targeting Medicare beneficiaries with promises of illegitimate COVID-19 tests in order to steal beneficiaries’ medical information and fraudulently bill federal health care programs.

December 13, 2019 | Daily News

The HHS Office of Inspector General plans to look at whether state Medicaid agencies are incorrectly paying Medicaid managed care plans for beneficiaries that have moved to a different state and may be part of two different Medicaid programs, but the head of the National Association of Medicaid Directors says it’s not clear why OIG is taking this up now since the payments have been relatively minor and the issue has been going on for some time.

November 22, 2019 | Daily News

CMS is planning an overhaul of Medicaid eligibility regulations after the national improper pay estimates for the program hit 14.9% for fiscal 2019, and the agency is developing a proposed rule focused on insufficient recordkeeping, eligibility verification, redeterminations and compliance with eligibility requirements when beneficiaries’ circumstances change.

November 22, 2019 | Daily News

The Medicare fee-for-service improper pay rate dropped again, according to the HHS fiscal 2019 financial report, dipping below the Medicare Advantage improper pay rate -- though that program’s improper pay rate dropped too, as did the Medicare Part D improper pay rate.

November 12, 2019 | Daily News

CMS proposed a wide-ranging new rule Tuesday (Nov. 12) that the agency says will crack down on states manipulating Medicaid supplemental payments in order to obtain extra federal matching funds.

October 24, 2019 | Daily News

CMS on Monday (Oct. 21) again asked about the best ways to use prior authorization – this time with a focus on using such policies to improve Medicare payment accuracy – and said it is also looking at how artificial intelligence could improve payments.

September 05, 2019 | Daily News

CMS on Thursday (Sept. 5) finalized a sweeping program-integrity rule -- first proposed under the Obama administration -- that gives the agency greater latitude to block health care providers from participating in Medicare, Medicaid or the Children’s Health Insurance Program if they are affiliated with entities who are deemed to pose a heightened risk of fraud, waste or abuse.

September 03, 2019 | Daily News

Illinois improperly paid Medicaid managed care plans on behalf of beneficiaries who were deceased, according to a new report from the HHS Office of Inspector General that is the latest in a series of audits that found at least eight states have issued Medicaid payments on behalf of dead people.

August 07, 2019 | Daily News

HHS recently withdrew rules proposed decades ago that would have codified the HHS Office of Inspector General’s ability to penalize hospitals that offer doctors incentives to reduce care for Medicare and Medicaid beneficiaries and would have expanded an existing safe harbor to include waivers of beneficiary cost sharing for those with certain Medigap plans.

June 20, 2019 | Daily News

CMS on Thursday (June 20) released guidance that makes clear CMS’ expectations for how states should make sure they correctly determine Medicaid eligibility for the expansion population after lawmakers raised concerns following recent audits from the Office of Inspector General and others that found some states did not correctly determine eligibility.

June 19, 2019 | Daily News

The House late on Tuesday (June 18) passed legislation that would fund the Money Follows the Person demonstration through 2024, preserve asset protections for the spouses of Medicaid beneficiaries who receive long term care benefits and extend the Community Mental Health Services Demonstration.

June 13, 2019 | Daily News

CMS is auditing California, Kentucky and New York — and will soon begin an audit of Louisiana — following reports that those states incorrectly determined Medicaid eligibility for some beneficiaries who received coverage through the Affordable Care Act’s Medicaid expansion, CMS Administrator Seema Verma said in a letter to Senate Finance Committee leaders.

May 02, 2019 | Daily News

The Trump administration late Wednesday (May 1) told a federal appeals court it agrees with a district judge’s ruling that the entire health care law is invalid, yet also asked the court to retain certain ACA provisions the administration claims would not harm the plaintiffs, including updates to Medicare fraud laws – a move that left key legal experts scratching their heads.

April 12, 2019 | Daily News

Federal Medicaid advisers voted Thursday (April 11) to recommend that Congress eliminate the requirement for states to establish a Recovery Audit Contractor program.

March 25, 2019 | Daily News

The Office of Inspector General (OIG) is asking for $10 million in additional funding in fiscal 2020 to target fraud, waste and abuse in home and community-based settings, with a focus on four geographic hotspots that OIG associates with “suspicious behavior” -- Florida, Texas, and select areas in Southern California and the Midwest.

March 22, 2019 | Daily News

The HHS Office of Inspector General is asking for an additional $2 million in fiscal 2020 to beef up the state Medicaid Fraud Control Units, and on Thursday the OIG finalized a regulatory update to the program that was initially proposed in 2016.

March 08, 2019 | Daily News

Senate Finance Committee Chair Chuck Grassley (R-IA) and health subcommittee Chair Pat Toomey (R-PA) on Friday (March 8) lambasted CMA for failing to recoup improper Medicaid eligibility-related payments in excess of 3 percent made by states since 1992 and asked the agency to respond by March 15 on how they plan to fix the situation and whether they need Congress’ help to do so.