Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Healthcare Fraud

CMS Extends Home Health Enrollment Suspension to Combat Fraud

January 31, 2018 - In an effort to reduce Medicare fraud, CMS announced in a new rule that it will extend a moratorium on enrollment of new Medicare home health agencies in Florida, Illinois, Michigan, and Texas. The federal agency also suspended enrollment of new Medicare Part non-emergency ground ambulance suppliers in New Jersey and Pennsylvania. The temporary halt of Medicare provider enrollment will also...


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VA Leverages CMS Data Analytics to Reduce Healthcare Fraud, Waste

by Jacqueline Belliveau

The country’s two largest public-private healthcare payment systems, the VA and CMS, recently announced that they will partner to reduce healthcare fraud, waste, and abuse for veterans using data analytics tools. “The VA-HHS alliance...

Physician Groups Pay $33M To Settle Healthcare Fraud Claims

by Jacqueline Belliveau

Two physician groups will pay over $33 million to settle healthcare fraud allegations that the groups received illegal kickback payments for patient referrals to hospitals owned by former Health Management Associates (HMA), the Department of...

GAO Offers Steps to Enhance Medicaid, Medicare Fraud Strategy

by Jacqueline Belliveau

CMS demonstrates a commitment to preventing and combating Medicaid and Medicare fraud, but the federal agency’s anti-fraud efforts only partially align with the Government Accountability Office’s (GAO) Framework for Managing Fraud...

Home Health Owners Face Charges for Medicare Fraud, Upcoding

by Jacqueline Belliveau

The federal government filed a lawsuit against the two owners of Gateway Health Systems in Chicago for their involvement in a Medicare fraud scheme that cost the federal healthcare program millions, the Department of Justice recently announced....

OK Physician Pays $580K to Settle Medicare Fraud Allegations

by Jacqueline Belliveau

A physician from Oklahoma recently agreed to pay $580,000 to settle a Medicare fraud case in which the federal government alleged that he submitted false claims to the federal healthcare program, the  Department of Justice (DoJ) announced....

New Medicare Fraud Audits to Ease Burden on Compliant Providers

by Jacqueline Belliveau

CMS recently updated its Medicare fraud and improper payment audit process to target providers and suppliers who continually demonstrate high medical billing error rates, according to the federal agency’s website. The new Targeted Probe...

LA Hospital Pays $42M to Settle Healthcare Fraud, Kickback Case

by Jacqueline Belliveau

Los Angeles-based Pacific Alliance Medical Center recently agreed to pay $42 million in order to settle an ongoing healthcare fraud case involving improper financial relationships between the acute care hospital and referring physicians. According...

Third MI Provider Convicted in $17.1M Healthcare Fraud Case

by Jacqueline Belliveau

Healthcare fraud prevention and prosecution will continue to be a major area of focus for the Department of Justice (DoJ), Acting Assistant Attorney General Kenneth A. Blanco recently told the American Bar Association. With healthcare fraud draining...

OIG Releases Healthcare Fraud Compliance Program Guidelines

by Jacqueline Belliveau

The Office of the Inspector General (OIG) recently published guidelines on how healthcare organizations can measure the effectiveness of their healthcare fraud compliance programs. The resource guide explains how healthcare organizations of all...

GA Dentist Sentenced to Prison for $1M Medicaid Fraud Scheme

by Jacqueline Belliveau

A dentist from Georgia faces one and a half years in federal prison after she reportedly participated in a Medicaid fraud scheme totaling almost $1 million, the Department of Justice (DoJ) recently announced. From 2009 to 2013, Oluwatoyin Solarin,...

HHS: Physician Self-Referral Law Hinders Value-Based Care

by Jacqueline Belliveau

Some healthcare fraud prevention regulations many impede value-based care models that use financial incentives to encourage providers to improve care quality and reduce healthcare costs, the Department of Health and Human Services (HHS) recently...

NY Clinic Manager Pleads Guilty in $70M Medicare Fraud Scheme

by Jacqueline Belliveau

A New York-based healthcare clinic manager recently pled guilty for his role in a Medicaid and Medicare fraud ring involving three clinics across New York City. The scheme to defraud federal healthcare programs resulted in $70 million in fraudulent...

Former Tenet Exec Charged in $400M Healthcare Fraud Scheme

by Jacqueline Belliveau

The Department of Justice (DoJ) recently announced the indictment of Tenet Healthcare Corporation’s former senior vice president of operations for his alleged participation in a healthcare fraud scheme totaling over $400 million in inappropriate...

HHS, DoJ Recovered $3.3B From Healthcare Fraud Cases in 2016

by Jacqueline Belliveau

Through healthcare fraud cases and settlements in 2016, Department of Health and Human Services (HHS) and Department of Justice (DoJ) initiatives returned over $3.3 billion to the federal government and individuals, including $1.7 billion to...

OIG Identifies Top HHS Financial, Medicare Fraud Challenges

by Jacqueline Belliveau

The Office of the Inspector General (OIG) recently found the most significant management and performance challenges facing the Department of Health and Human Services (HHS), including financial management and Medicare fraud prevention inefficiencies....

GA Provider Receives Jail Time for a Healthcare Fraud Scheme

by Jacqueline Belliveau

A Georgia-area provider has recently been sentenced to three years and two months in prison stemming from a healthcare fraud case, the Department of Justice (DoJ) reported. Robert E. Windsor of Georgia was charged with fraudulent medical billing...

Former Hospital Exec Pays $1M to Settle Medicare Fraud Case

by Jacqueline Belliveau

The former chief executive officer of a South Carolina-based healthcare system agreed to pay $1 million and be excluded from federal healthcare programs for four years to resolve a 2013 Medicare fraud case, according to the Department of Justice...

Provider Org Pays $3M for Violating Medicare Fraud Resolution

by Jacqueline Belliveau

Kindred Healthcare, Inc., the country’s largest provider of post-acute care, recently paid more than $3 million for failing to comply with a Medicare fraud resolution agreement. It represents the largest penalty ever doled out by the Office...

CMS Proposes to Expand Medicaid Fraud Control Unit Authority

by Jacqueline Belliveau

A recently proposed rule would codify several statutory changes involving Medicaid Fraud Control Units, including the authority to investigate patient and abuse cases at healthcare facilities regardless of if they receive Medicaid payments.*...

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