In the latest episode of Payers, Providers, and Patients – Oh My!, Jacinta Alves talks with Joe Records and Payal Nanavati about health care compliance programs.
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Podcast: FCA Dismissals under the Granston Memo
In our first episode of Payers, Providers, and Patients – Oh My!, John Brennan talks with Joe Records and Payal Nanavati about FCA dismissals under the Granston Memo.
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Highlights from the Comments on the Proposed Elimination of Discount Safe Harbors for Rebates
Nearly 20,000 comments have been submitted in response to the Department of Health and Human Services January 31, 2019 notice of proposed rulemaking eliminating discount safe harbor protection for reductions in price to prescription pharmaceutical products (or rebates) provided by manufacturers to plan sponsors under Medicare Part D and Medicaid managed care organizations (MCOs), whether negotiated by the plan or by pharmacy benefit managers (PBM) or paid through a PBM to the plan or Medicaid MCO. Most of the comments appear to be relatively short, text box comments submitted by individuals through patient or business advocacy groups. The following is a very high level summary of the several hundred comments posted (so far) from health plans, manufacturers, pharmacies, their respective associations, and policy oriented groups:
Continue Reading Highlights from the Comments on the Proposed Elimination of Discount Safe Harbors for Rebates
New Strategies to Help False Claims Act Health Care Defendants
On Nov. 29, 2018, Deputy Attorney General Rod J. Rosenstein announced several amendments to policies on individual accountability set forth in the 2015 Yates Memo. As a result, companies facing FCA actions—especially defendants in health care cases—should consider following three strategy tips: (1) Establish clear benchmarks for cooperation. (2) Advocate for individual releases. And (3)
CMS Announces and Solicits Comments on Expanded RADV Audit Methodology
In its recent notice of proposed rulemaking setting policy for Medicare Advantage (MA) and the Prescription Drug Program (PDP) for calendar year 2020, CMS announced that it would establish extrapolation as a method to be used in risk adjustment validation (RADV) audits, and further, that it would not make any adjustments to account for errors in Medicare fee for service data in determining recovery amounts.
CMS uses a risk adjustment process to modify MA plan payments to better reflect the relative risk of each plan’s enrollees. Payments to each MA plan are adjusted based on risk scores that reflect enrollees’ health status (categorized into Hierarchical Condition Categories (HCCs)) and demographic characteristics derived from member claims data. To counteract incentives that a plan might have to over-report enrollee diagnoses, CMS emphasizes that all diagnoses submitted to enhance risk must be documented in a medical record, and uses RADV audits to ensure that medical record documentation exists, and thus, that payments to MAOs accurately reflect the level of risk assumed.
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Opioid Legislation: Expanding the Sunshine Act
On October 3rd, the United States Senate passed a bipartisan opioids package with a sweeping vote of 98 to 1, after the U.S. House of Representatives passed the final version of the bill with a vote of 393 to 8. One of its components, the “Fighting the Opioid Epidemic with Sunshine Act,” expands the scope
GAO and CMS Seek Increased Scrutiny on Medicaid Managed Care Organizations
Federal agencies are signaling closer oversight of Medicaid managed care organizations (“MCOs”). On August 21, 2018, the U.S. Comptroller General Gene Dodaro and Centers for Medicare and Medicaid Services (“CMS”) Administrator Seema Verma testified to the Senate Homeland Security and Governmental Affairs Committee about combating Medicaid fraud and urged additional oversight of Medicaid MCOs and a larger restructuring of the Medicaid program. This testimony follows other steps taken by the Governmental Accountability Office (“GAO”) and CMS earlier this year to encourage increased scrutiny of Medicaid managed care programs.
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Health Care Fraud and Abuse Control Program FY 2017: Insights from Our Enforcement Team
The Health Care Group’s newest partners, William S.W. Chang and Laura M. Kidd Cordova, along with Counsel Stephanie D. Willis, have authored an Alert about the 21st Health Care Fraud and Abuse Control Program (HCFAC) annual report released last Friday. The HCFAC report is a joint effort of the U.S. Department of Justice (DOJ) and
Hospitals Beware: Medicare Electronic Health Records Incentive Payments to Hospitals are in the OIG’s Crosshairs
The Department of Health and Human Services, Office of the Inspector General (OIG), modified its Work Plan to announce that the agency will be conducting a nationwide audit of hospitals that participated in the Medicare Electronic Health Records (EHR) Incentive Program (also known as the Meaningful Use Program). The OIG review is focusing on hospitals
Upcoming Webinar: Looking Back & Looking Beyond – The First 100 Days in Health Care Policy
On Tuesday, April 18, 2017, our Health Care Group will hold a webinar on the health care policy and transition challenges still at play as the Trump Administration nears the end of its 100 days in power. During the webinar, participants will hear important insights and predictions on what a Trump-led Executive Branch will mean