Category: Blog

Highlights of the General Audit Process

Highlights of the General Audit Process General Audit Process

Typically, a letter announcing the intention of an audit is sent to the company.  However, I have experienced where State Agents came directly into a clinic and started the investigation immediately on premises.  In this case, the investigation was based on a complaint issued to the State Medicaid agency.  Having Federal and State Agents come […]

Ways a Health Plan Audit Can Be Initiated

Ways a Health Plan Audit Can Be Initiated Health Plan Audit

There are several ways that a Health Plan audit can be initiated: As a result of pre-delegation audit and annual audit findings From a delegation/contractual standpoint, there can be Key Performance Indicators (KPIs) that must be met for a health plan to remain in compliance with the Centers for Medicare and Medicaid Services (CMS).  For […]

January – June 2022 H1 Healthcare Data Breach Report

January – June 2022 H1 Healthcare Data Breach Report

August 29, 2022

Companies handling patient data on behalf of healthcare providers and insurers – known as business associations under the Health Insurance Portability and Accountability Act – accounted for 14.5% of the healthcare breathes reported in the first half of 2022, but 22.9% of compromised records, according to a report from cybersecurity company Critical Insight.

Customers Perceive Shortfall in Medicare Advantage Plan Coverage of Mental Health and Substance Abuse Services, J.D. Power Finds

Customers Perceive Shortfall in Medicare Advantage Plan Coverage of Mental Health and Substance Abuse Services, J.D. Power Finds

August 19, 2022

This is an interesting in article, just published yesterday from JD Power regarding Medicare Advantage (MA) plans and mental health coverage. 

According to the study conducted by JD Power, patient satisfaction with MA plans has increased in the last year, however, patients have indicated that there is inadequate coverage for mental health and substance use disorders.  The senior population has been significantly affected by the pandemic (loneliness, isolation), including many aspects around Social Determinants of Health (SDOH) such as Community, Safety & Social Context (e.g., social integration, support systems, community engagement) and Health Care System (e.g., health coverage, access/availability, and quality of care). 

The OIG has become more sophisticated in their detection and fight against fraudulent schemes.

The OIG has become more sophisticated in their detection and fight against fraudulent schemes.

July 6, 2022

In an interview with Health Care Compliance Association (HCCA), the new Inspector General of HHS-OIG, Christi A. Grimm indicated that their focus continues to be around compliance and fraud, waste, and abuse. 

July 1, 2022

The FBI Internet Crime Complaint Center (IC3) issued a warning to employers that stolen Personally Identifiable Information (PII) and Deepfakes are being used by bad actors to apply for remote work and work-from-home positions.  The types of positions being targeted by these bad actors include:  information technology and computer programming, database, and software related job functions.  If hired, these bad actors could have “access to customer PII, financial data, corporate IT databases and/or proprietary information.”

DOJ Reaches $22.7 Million Settlement with Providence Over Medically Unnecessary Neurosurgery Procedures

DOJ Reaches $22.7 Million Settlement with Providence Over Medically Unnecessary Neurosurgery Procedures

Thomas Sullivan Last Updated May 30, 2022

The Department of Justice had a $22.7 million settle with Providence Health & Services Washington (Providence) to resolve allegations that Providence inappropriately billed claims to federal programs (Medicare, Medicaid, Tricare, etc.) for services that were not medically necessary.