Blog
Health Care Fraud – What the Government Must Prove
Health Care Fraud is one of the most common white collar crimes charged by the Federal Government. The Health Care Fraud statute states: (a)Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice— (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, […]
How Medicare Providers can Fight a Medicare Recoupment
CHICAGO – Medicare and Medicaid providers are more often than ever facing audits from government agencies, regulators, or their surrogates. When contacted by any such an entity the first step is to determine your potential liability and exposure. Too many times, I have seen providers expose themselves needlessly to a criminal prosecution based on what started […]
DOJ False Claims Act Policy Memo
Chicago – The Department of Justice issued an internal memorandum on January 10, 2018, which was soon released publicly and can be found here. The memorandum was quickly praised by the False Claims Act defense bar, but a reasoned review of the memorandum shows that the plaintiff bar should also welcome the policy statements outlined […]
Fixing the ALJ Backlog
In 2014, the American Hospital Association sued the Secretary of Health and Human Services to compel HHS to clear the delay in the Medicare administrative appeals process and to comply with the statutory ninety-day time frame for Administrative Law Judge hearings. (The August 11, 2017, court of appeals opinion can be found here.) Congress directed […]
How to Advance your Medicare Appeal after a Reconsideration by a QIC
If you are appealing a reconsideration issued by a Qualified Independent Contractor (QIC) and you have not received a decision within 90 days you may have the right to have your appeal escalated to the next level before the Medicare Appeals Council. An appellant who has properly filed a request for hearing before an Administrative […]
Changes to the Medicare Appeals Process
The Centers for Medicare and Medicaid Services (CMS) part of the Department of Health and Human Services (HHS) issued a final rule on January 17, 2017 titled “Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures,” (Final Rule), that went into effect March […]
False Claims Act case against Lance Armstrong Cycle’s On
Back in 1995, the United States Postal Service (USPS) sponsored the cycling team headed by Lance Armstrong, its top rider. In 2000 Lance Armstrong won the Tour de France and the USPS renewed its sponsorship of the team so long as Armstrong remained part of it. The USPS paid about $32 million to the team […]
Medicare Abbreviations
Medicare and its regulation are replete with abbreviations, acronyms, and content specific phrases. The link below contains a list of 75 and growing. I hope you find this list helpful. If you have any additions, please contact me and I will include them. Mike Abbreviations – Health Care
Medicare Audits and Appeals
When Medicare conducts an audit of a provider and concludes that an overpayment has occurred it will attempt to recoup that overpayment. This article will discuss the overpayment appeals process. There are five levels of appeal, each of which is considered a completely new examination of the audit and determination. Unlike a judicial appeal […]
Is that Medicare patient Homebound?
One Medicare policy that has seen a boom in litigation, both civil and criminal, in the past few years relates to services being provided to allegedly homebound Medicare beneficiaries. Homebound status is defined in the Medicare Benefit Policy Manual and states that for a patient to be eligible to receive home health services under Medicare, […]