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OIG Semiannual Report to Congress

OIG issued its Semiannual Report to Congress summarizing the activities of the Department of Health and Human Services (HHS), Office of Inspector General (OIG), for the 6-month period ending on March 31, 2020. The OIG noted that during this reporting period, there were 443 criminal actions, 370 civil actions, 903 exclusions, and an expected $1.51 […]

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Justice Department accuses Anthem of Medicare fraud

Yet another allegation of Medicare Advantange risk adjustment fraud, this time by Anthem. I wrote about the government’s case against Cigna here. The case alleges that Anthem falsely certified the accuracy of the diagnostic data it sent to the Centers for Medicare and Medicaid Services, causing CMS to calculate risk-adjustment payments to the insurer based […]

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Private Schools and the Intersection of HIPAA and FERPA

My wife works as an Administrative Assistant at a local private school. As you might expect, they take very seriously their responsibility to help stop the spread of COVID-19 in the community. As part of their efforts, they require students who were in direct contact with persons diagnosed with COVID-19 to quarantine at home, away […]

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CMS Encourages Faster COVID-19 Diagnostic Testing

CMS is changing its payment methodology to encourage higher throughput of COVID-19 diagnostic testing. Previously, CMS would reimburse $100 per test Starting January 1, 2021, Medicare will pay lower the base rate to $75. However, if the laboratory can complete the test within two (2) calendar days from the date the specimens is collected, CMS […]

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DOJ sues Cigna, alleging $1.4B in Medicare Advantage fraud

Cigna falsified the health conditions of its Medicare Advantage plan members to coax CMS into making larger payments to the insurer on behalf of beneficiaries, a U.S. Justice Department lawsuit alleges. Medicare Advantage organizations get reimbursed by Medicare based on a formula that takes into account the patient population’s acuity levels. Risk adjustment scores adjust […]

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CMS Issues Cease and Desist Orders to Uncertified Labs Performing COVID-19 Testing

Since August 12, 2020, CMS issued 171 cease and desist letters to entities across the U.S. that were testing for COVID-19 without the appropriate certifications under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Every facility that conducts COVID-19 testing is considered a “laboratory” and must be certified under CLIA, which verifies that labs meet […]

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Data Breaches Can Result in Federal and State Liability

Regulatory bodies continue to impose severe penalties on covered entities who fail to protect patient data from unauthorized disclosure. Community Health Systems, Inc. recently settled claims with HHS Office of Civil rights resulting from a 2014 data breach that exposed personal information of approximately 6.1 million patients for $2.3 million. But settlement with the federal […]

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Two charged in prescription and kickback scheme

An 11-count indictment unsealed on Friday charges former Kindred Home Health employee Amber Price, 37, and Christopher Cruz, 46, owner of a medical marketing business, CP Cruz Management Group, LLC (Cruz), with one count of conspiracy to violate the federal anti-kickback law. Under the alleged scheme, Price and Cruz would create fraudulent prescriptions using actual […]

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Medical Device Maker to Pay $18 Million to Settle Allegations of Improper Payments to Physicians

This is not a Texas company, but it is a good example of how some manufacturers try to cloak improper payments under the veil of legitimate compensation. The device manufacturer paid millions of dollars in “advertising assistance, practice development, practice support, and purported unrestricted educational grants” directly to local healthcare providers to induce sales of […]

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OCR Settles Eighth Investigation in HIPAA Right of Access Initiative

Since 2019, the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) has been prioritizing enforcement actions against covered entities that do not allow patients timely access to their health records at a reasonable cost as required by HIPAA. This month, OCR settled an eighth investigation for $160,000 and […]