August 7, 2023

Approximately 612,000 Medicare beneficiaries have been impacted by a data breach involving a Medicare contractor.  On June 2, 2023, the Centers for Medicare & Medicaid Services (CMS) was notified by Maximus Federal Services (provide CMS with appeals services) of a data breach involving protected health information/personally identifiable information (PHI/PII) of approximately 612,000 Medicare beneficiaries.  The breach was caused by a vulnerability in a third party’s transfer software, MOVEit.   This software application, now a part of Progress Software, encrypts files and uses file transfer protocols such as FTP(S) or SFTP to transfer data, as well as providing automation services, analytics and failover options.  (See the CISA Alert)  No CMS systems were impacted.

August 1, 2023

Medicare Advantage (MA) plan, Martin’s Point Health Care, Inc. in Portland Maine, has agreed to settle false claims act allegations with the DOJ, for approximately $22.5 million.  This whistleblower case was brought on by a former manager of Martin’s Point’s Risk Adjustment Operations team, who will receive approximately $3.8 million.

July 28, 2023

A Michigan health system (Sparrow) settled with the DOJ and agreed to pay $671,310 to resolve False Claims Act issues based on the improper billing of “incident-to” services.  Incident-to services are furnished incident to a physician’s professional services when they are an integral part of the services provided by a physician. 

May 25, 2023

A primary care group will settle with the Department of Justice (DOJ) for submitting unsupported diagnoses to the Medicare Advantage (MA) program.  Complete Physician Services (CPS) in Philadelphia will pay $1.5M plus interest to settle False Claims Act (FCA) violations for submitting unsupported diagnoses to the MA program. 

May 19, 2023

On May 17, 2023 the Senate Permanent Subcommittee on Investigations (PSI) conducted a hearing looking into denials and delays of care in the Medicare Advantage (MA) program. 

Some key points discussed by Senators Blumenthal and Johnson included:

MA beneficiaries facing barriers to access of care and treatment
Delays/denials in medically necessary care
MA plans not offering, at a minimum, the same benefits and coverage criteria as original Medicare
MA plans are using proprietary tools (algorithms and Artificial Intelligence (AI)) to make patient care decisions
There is a need for transparency by MA plans on how they utilize these tools
The three big MA plans (United HealthCare, Humana, and CVS/Aetna) were sent a Senate bipartisan letter on May 17, 2023 asking for internal documents to be provided, which describe how prior authorization decisions were made, to include the utilization of AI tools
Lack of free-market competition in the MA space

May 12, 2023

The Office for Civil Rights (OCR) announced on April 11, 2023 that providers will have 90-days after the end of the Public Health Emergency (PHE) to become compliant with the HIPAA Rules (HIPAA Privacy, Security and Breach Notification Rules) for telehealth services.  Since the beginning of the PHE, the OCR has utilized Enforcement Discretion to determine how violations with privacy, security, and breach notifications would be managed.  The PHE ended on May 11, 2023.  Providers now have a 90-day transition period (until August 9, 2023) to be compliant with the HIPAA Rules.  (Enforcement Discretion for Telehealth Remote Communications During the COVID–19 Nationwide Public Health Emergency – PDF (“Telehealth Notification”), effective from March 17, 2020, to 11:59 pm May 11, 2023.) 

May 11, 2023

HPMS published a memo on May 9, 2023 addressing coverage for over-the-counter (OTC) COVID-19 tests for Medicare Advantage (MA) & Medicare-Medicaid (MMPs) health plans.  Typically, Medicare Part B does not cover OTC tests, but with the pandemic, free OTC COVID-19 tests were available to Medicare beneficiaries.  With the end of the Public Health Emergency (PHE) on May 11, 2023, free OTC COVID-19 tests will no longer be available.

May 11, 2023

As of today, the COVID-19 PHE flexibilities issued by the Office of Inspector General (OIG) have come to an end.  They “were designed to provide flexibility and minimize burdens for the health care industry as it faced the challenges of the COVID-19 pandemic.”

Read the latest information published by the OIG https://oig.hhs.gov/coronavirus/covid-flex-expiration.asp and previous blogs from The Honest Approach regarding the ending of the PHE.

May 05, 2023

UNBELIEVABLE!  Many times when I see Press Releases from the Department of Justice (DOJ) a couple thoughts go through my head…. “If only they had a better compliance program in place that conducted audits and monitored potential issues, this might not have cost them $XX millions of dollars.” Or, I think … “Wow!  That was BOLD!”  This is one of those times that I pull out the BOLD thought and add on a “slap my head” emoji! 

May 4, 2023

The Office of Inspector General (OIG) addresses reinstatement to participate in Federal healthcare programs after an individual or entity’s state license has been revoked, suspended or surrendered here: (https://www.oig.hhs.gov/exclusions/reinstatement.asp)

Individuals or entities who have been excluded from participating in Federal healthcare programs can apply to be reinstated upon:

Completion of their defined exclusion period – they can start the application process 90-days before the end of the exclusion period
Regaining licensure that was excluded