May 8, 2023
HPMS released a memo with the upcoming deadlines for Medicare Advantage Organizations, etc. to submit their risk adjustment data to calculate risk scores for Payment Years 2022, 2023, 2024, and 2025. Data must be submitted by 8pm on the day of the deadline to be counted in the current run. Submissions after 8pm will be included in the mid-year or final reconciliation run, based on deadline date. See the table below and review the HPMS site for more details.
March 21, 2023
HealthExec’s March 20, 2023 article listed the top 10 best & worst states for physicians. This ranking was based on research conducted by WalletHub who compare the 50 states and the District of Columbia across 19 key metrics, including salary, number of hospitals in the per capita area, and quality.
March o2, 2023 With the Public Health Emergency (PHE) expiring on May 11, 2023, CMS updated their CMS PHE Fact Sheet on February 27, 2023. This fact sheet covers the following: COVID-19 vaccines, testing, and treatments; Telehealth services; Health Care Access: Continuing flexibilities for health care professionals; and Inpatient Hospital Care at Home: Expanded hospital […]
03/01/23
James Luketich, MD and associated entities have agreed to pay $8.5M and initiate a Corrective Action Plan to settle False Claims allegations that Dr. Luketich “regularly performed as many as three, complex surgical procedures at the same time, failed to participate in all of the “key and critical” portions of his surgeries, and forced his patients to endure hours of medically unnecessary anesthesia time, as he moved between operating rooms and attended to other patients or matters.”
02/27/23
On January 24, 2023, CMS conducted its quarterly stakeholder call and reviewed 2022 successes and provided a high-level overview of their 2023 plans and initiatives. CMS Strategic Pillars (see infographic) were highlighted by each CMS leader who discussed their area of responsibility.
01/11/23
The government continues to actively enforce the False Claims Act [31 U.S.C. §§ 3729-3733] (FCA) which states that “it is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.” Examples of this include filing claims that are not medically necessary, billing for services not rendered, billing for a service at a higher level than actually performed (upcoding), etc.
Health plans can gain access into the company’s system. This will depend on what is in the company’s contract/Agreement with the health plan.
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 […]
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 […]
For two years, millions of the nation’s healthcare workers have been battling the coronavirus. Many have endangered themselves as they care for those who contract COVID-19 while working in high-risk settings that expose themselves and their families.
