The Program for Evaluating Payment Patterns Electronic Report (“PEPPER”) is an electronic data report under contract with the Centers for Medicare & Medicaid Services (“CMS”) that helps guide hospital’s auditing and monitoring services. In 2014, PEPPER published new target areas for Short-Term Acute Care hospitals that were identified as prone…
On Tuesday, May 13, 2014, the Department of Justice (“DOJ”) and Department of Health and Human Services (“DHHS”) held a joint news conference to announce that the Medicare Fraud Strike Force had conducted a nationwide takedown of 90 individuals involving approximately $260 million in fraudulent Medicare billings. The nationwide takedown…
In December of 2013, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Quotes for new Recovery Auditor (RAC) contracts. The new contracts include significant changes to payment terms. Whereas the current contracts allow payment to RACs after the first level of appeal has been exhausted (120…
On May 7, 2014, the Department of Health and Human Services (“HHS”), New York-Presbyterian Hospital (“NYP”) and Columbia University (“CU”) agreed to collectively pay $4.8 million to settle charges of alleged violations of the HIPAA Privacy and Security Rule marking the largest HIPAA settlement to date. OCR initiated an investigation…
The final budget bill was recently passed in New York State containing several provisions for Out-of-Network (“OON”) reforms. The major changes related to OON reform include: 1) transparency provisions requiring the reestablishment of “usual, customary and reasonable” or “UCR” charges to determine reimbursement rates; 2) adding protections allowing patients to…
The Centers for Medicare & Medicaid Services (“CMS”) announced in a Federal Register notice that it is creating a new data-collection program for hospice quality reporting called the Hospice Item Set (“HIS”) System. The HIS System, which is mandated under Section 3004(c) of the Patient Protection and Affordable Care Act…
On April 2, 2014, the Centers for Medicare & Medicaid Services (“CMS”) announced its intent to publish data on its payments to individual physicians. Beginning on April 9, 2014, CMS plans to release information regarding the charges for medical services and procedures furnished by physicians and other health care professionals.…
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It is customary for insurers to deny claims submitted by no-fault providers, and providers, in turn, commonly challenge these denials. Conversely, it is anomalous for a no-fault provider to initiate a (putative) class action suit in response to an insurer’s payment denials. Yet, in a recently filed action, an aggrieved…
The Centers for Medicare & Medicaid Services (“CMS”) announced changes to the Medicare Fee-For-Service Recovery Audit Program in a posting on the CMS.gov website February 18, 2014. According to CMS, the changes will go into effect after the new Recovery Audit Program contracts are awarded. The announcement includes changes to…