Healthcare, Senior Living, Economics
According to a Wall Street Journal article from August 4, Medicare Advantage plans are using home nurse visits to identify possible or questionable disease states/conditions (so called, phantom diseases) via screenings. These diagnoses then turn into what appears to be, possible events of fraud via additional reimbursement tied to these new-found conditions. Exclusive | The … Read more
Since I started this site, a topical area that has been a constant for me is hospice and in particular, fraud and abuse. Recent cases have again put Hospice fraud and abuse, front and center. Thematically, the cases are different and the same in so much that they involve improper billing of hospice cases to … Read more
It was only a matter of time before cases involving telehealth fraud/False Claims Act cases became public. This week, two press releases from the DOJ illustrated how aggressive the agency has become in the pursuit of telehealth related fraud. I suspect more, larger in implication (dollar value, geographic spread), will drop publicly in the next … Read more
A couple of weeks ago, on February 22nd. the Department of Justice issued its annual statement regarding False Claims Act activity in FY 2023 (federal fiscal years run 10/1 to 9/30). “Settlements and judgments under the False Claims Act exceeded $2.68 billion in the fiscal year ending Sept. 30, 2023. The government and whistleblowers were … Read more
Happy Hump Day! Long title for what is going to be, a rather brief post. As followers and regular readers know, my firm (I am the co-founder and part owner) H2 Healthcare, LLC has a practice area uniquely concentrated on clinical compliance and complex litigation support. The practice area is headed by Diane Hislop, RN (yes, … Read more
In 2023, regulators re-instituted audits of facilities for inappropriate diagnoses of schizophrenia (justification for anti-psychotic use), plus a five-claim audit of every nursing home. The purpose of the audit was to address a long-standing concern that inappropriate coding was driving higher Medicare reimbursement under PDPM, despite documentation in patient records, not substantiating the level of care … Read more
A complex area for providers, especially with respect to their compliance programs, are the concepts of fraud and abuse. Central to current requirements for compliance programs, all post-acute providers are REQUIRED to have compliance programs that, Include policies and procedures to define, test for, and mitigate any issues pertaining to fraud and abuse. In this … Read more
Recently, CMS announced that its Medicare Audit Contractors (MACS) would soon commence (June 5) a five-claim audit process for every nursing home in the nation participating in the Medicare program. The reviews are set to occur on a rolling basis whereby each MAC in its region, will begin by pulling five Medicare claims from each … Read more
I know I sound redundant but clearly, the message is still not permeating through the industry (except for readers here). The Department of Justice and the OIG for the Department of Health are scrutinizing SNFs, their therapy billings, and the use of therapy contractors. Why? It is all due to a known and now routinely … Read more