Category: COMPLIANCE

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 […]

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. 

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.

Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples Health Network (Contract H1961) Submitted to CMS

Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Peoples Health Network (Contract H1961) Submitted to CMS

Of the 242 unique enrollee-years that were audited, 98 had validated medical records that supported the HCC (Hierarchical Condition Categories) diagnoses submitted.  The other 144 unique enrollee-years diagnoses were not supported by the medical records, because Peoples Health was not able to locate the medical records.

Salisbury Medical Practice Pays the United States Over $286,000 to Resolve Claims that it Billed for Medical Services Not Provided

Salisbury Medical Practice Pays the United States Over $286,000 to Resolve Claims that it Billed for Medical Services Not Provided

Peninsula Internal Medicine, L.L.C., a medical practice located in Salisbury, Maryland, and the Estate of Candy Burns have paid the United States $286,631.33 to settle allegations that Peninsula Internal Medicine (“PIM”) and its former owner, Candy Burns, submitted false claims to the United States for medical services that were not provided.  

Windham Eye Care Practice and its Owners Pay $192K for Employing “Excluded” Individual

Windham Eye Care Practice and its Owners Pay $192K for Employing “Excluded” Individual

Leonard C Boyle, United States Attorney for the District of Connecticut, today announced that WINDHAM EYE GROUP, P.C., an ophthalmological medical practice located in Windham, and its owners, DANA WOODS, M.D. and WILLIAM KAUFOLD, M.D., have entered into a civil settlement agreement with the federal and state governments to resolve allegations that they improperly employed an individual who was excluded from all federal healthcare programs.