Skip to the contentFraud & Abuse
- Horizon Medical Center of Denton, owned by Corinth Investor Holdings, L.L.C., paid $14.2 million to settle potential violations of Medicare regulations and the Stark Law. The center self-disclosed omitting a modifier and location for services provided at off-campus facilities, as well as financial relationships with physician-owners. This settlement, along with two others, highlights the Department of Justice’s emphasis on voluntary self-disclosure and cooperation in healthcare fraud cases.
- A pharmaceutical ingredient supplier will pay $21.75 million to settle allegations of inflating Average Wholesale Prices (AWPs) for two key ingredients. A pharmacist whistleblower exposed the scheme, highlighting the critical role of whistleblowers in combating pharmaceutical fraud. The False Claims Act empowers individuals to report fraud and protects public funds from fraudulent activities.
- A Texas optometrist, agreed to pay $1 million to settle allegations of healthcare fraud. The doctor operated a network of optometry practices in Central Texas and according to the government, these practices submitted claims to TRICARE, Medicare, and Medicaid using the National Provider Identifiers (NPIs) of optometrists who did not perform the services billed. They allegedly did so “in circumstances where the optometrist who rendered services was not credentialed or enrolled in the Federal healthcare program billed.
- Oak Street Health, a CVS subsidiary, agreed to a $60 million settlement for violating the False Claims Act. The company allegedly paid kickbacks to insurance agents to recruit seniors to their clinics, resulting in false claims to Medicare. The settlement includes restitution and a whistleblower reward.
HIPAA & Cybersecurity
Hospice
Insulin Overpricing
Loper Bright
Med Spas
No Surprises Act
Physician Fee Schedule
- The Centers for Medicare & Medicaid Services (CMS) finalized the 2025 Medicare Physician Fee Schedule, resulting in a 2.93% reduction in average payment rates. This decision has been met with strong opposition from national provider associations, who argue that the cuts, coupled with inflation, threaten the financial viability of physician practices and patient access to care. These associations urge Congress to intervene and stabilize reimbursement rates.
- The Biden administration finalized 2025 Medicare reimbursement rates, with physicians facing a 2.9% decrease and hospitals receiving a 2.9% increase for outpatient services. While hospitals argue the rates are insufficient, physician groups, particularly those operating independent practices, face more significant challenges due to rising costs and smaller profit margins. The CMS also implemented changes to the Hospital Outpatient Prospective Payment System, including maternal health and safety standards and continuous coverage requirements for children in safety-net programs.
- CMS finalized a 2.83% physician pay cut for 2025 while increasing reimbursement for ASCs meeting quality reporting requirements. The rule includes updates to coding and payment policies for various services, as well as changes to the ASC quality reporting program.
Ransomeware
- Ransomware attacks, while slightly less frequent in H1 2024, saw a 68% increase in severity, with average losses reaching a record high. Businesses with over $100 million in revenue experienced the most significant impact, with a 140% increase in losses. While BEC attacks remained the most common cause of claims, ransomware attacks were the third most common, with exposed login panels and outdated technologies increasing the likelihood of a claim.
- A new report reveals a four-year high in ransomware attacks on healthcare organizations, with 67% reporting incidents in the past year. These attacks are increasingly complex, with longer recovery times and higher costs, averaging $2.57 million in 2024. Attackers are also targeting data backups, increasing pressure on organizations to pay ransoms.
Skilled Nursing Facilities
