Tag Archives: overpayment

Exaggerated Diagnosis Codes and Inadequate Provider Networks: Allegations of Medicare Advantage Fraud Settled for $32.5 Million

By Kevin Bradberry on June 20, 2017 Posted in Uncategorized

The latest settlement involving Medicare Advantage (MA) organizations highlights not only the government’s continuing enforcement focus on Medicare Part C but also the vulnerabilities inherent in that program. In United States ex rel. Sewell v. Freedom Health, Inc. et al., two Florida-based MA organizations – Freedom Health and Optimum HealthCare – agreed to pay $32.5 … Continue Reading

The DOJ Enters Another FCA Lawsuit Against UnitedHealth

By B. Scott McBride and Jennifer Whitton on May 30, 2017 Posted in Uncategorized

The U.S. Department of Justice (DOJ) recently filed its complaint in intervention in another whistleblower lawsuit brought under the False Claims Act against the nation’s largest owner and operator of Medicare Advantage (MA) organizations, UnitedHealth Group, Inc. (United). The DOJ’s 39-page complaint alleges that United had fraudulently obtained inflated risk adjustment payments by over reporting diagnosis … Continue Reading

The 60-Day Rule: Failure to Return Overpayments Caused by Software Glitch Costs Hospital $2.95 Million

By Kevin Bradberry on October 31, 2016 Posted in Uncategorized

A software glitch can be just as risky for a healthcare provider as submitting a false claim. Or so it was declared on August 24, 2016 when the U.S. Attorney for the Southern District of New York announced that Continuum Health Partners, Inc. and two of its New York City network hospitals would pay $2.95 … Continue Reading

The Deeper Dive: The Final Overpayment Rule

By B. Scott McBride and Darby C. Allen on February 26, 2016 Posted in Uncategorized

The Centers for Medicare and Medicaid Services (CMS) recently issued its final rule for Reporting and Returning of Overpayments (Final Rule). The Final Rule implements section 1128J(d) of the Social Security Act, which requires Medicare providers and suppliers to report and return overpayments within 60 days after the overpayment was identified in most instances. Failure to report … Continue Reading

Breaking News: 60-Day Overpayment Rule Finalized

By B. Scott McBride and Darby C. Allen on February 11, 2016 Posted in Uncategorized

The Centers for Medicare and Medicaid Services (CMS) released its final rule implementing Section 6402(a) of the Affordable Care Act that requires Medicare providers and suppliers to report and return overpayments within 60 days after the date on which the overpayment was identified in most instances. Failure to report and return overpayments in accordance with … Continue Reading

Kane and the “60-Day Rule”: The Unforgiving World of Medicare and Medicaid Overpayments

By B. Scott McBride and John W. Petrelli on August 13, 2015 Posted in Uncategorized

The Southern District of New York has spoken on one of the first issues to confront those seeking compliance with the new “60-day rule” under the Affordable Care Act (ACA), and it does not bode well for defendant hospitals and providers. On August 3, 2015, the district court in Kane v. Healthfirst, Inc., issued its … Continue Reading

Breaking News: CMS Delays Final Overpayment Rule

By B. Scott McBride and Darby C. Allen on February 16, 2015 Posted in Uncategorized

Today, the Centers for Medicare and Medicaid Services (CMS) announced that it is extending the deadline to finalize the rule implementing the Affordable Care Act provision that requires providers to timely report and return overpayments to the Medicare program. The proposed rule was issued in February 2012, and CMS is required to provide notice to … Continue Reading