If wrong-doing is identified, based on health plan audits or evaluation of information, the company and company’s officials could face certain penalties, fines, and risks. The penalties and fines will be based on the type of offense, how egregious the offense is, how long it has been going on, how much harm it has done […]
Category: Blog
Health Plan Audits: Access into Systems
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.
Highlights of the 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
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
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
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).
When Utilizing Offshore Companies, Be Sure The Highest Standards of HIPAA Privacy and Security Are In place
July 7, 2022
CEO of Raleigh Healthcare Company Pleads Guilty to Multi-Million Dollar Healthcare Fraud
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.”
False Claims Act Violations
June 30, 2022
Molina Healthcare, Inc. (Molina) and its previously owned subsidiary, Pathways of Massachusetts (Pathways), have agreed to pay $4.625 million to resolve allegations that it violated the False Claims Act by submitting reimbursement claims while violating several regulations related to the licensure and supervision of staff.