Healthcare providers recently secured a significant legal victory regarding the No Surprises Act (NSA) and its independent dispute resolution (IDR) process. While the NSA was designed to protect patients from surprise medical bills, disputes between providers and insurers have persisted, particularly when it comes to the IDR process used to…
Healthcare fraud, waste, and abuse laws apply to any entity doing business in the healthcare space and especially those submitting claims to government healthcare plans or programs, such as Medicare and Medicaid. The three most important and influential healthcare fraud, waste, and abuse laws are the federal laws: the Physician…
Corporate Practice of Medicine, or CPOM for short, is a legal doctrine that refers to who is authorized to own and operate a medical practice and, specifically, to employ physicians. Most states regulate CPOM in one way or another, on the rationale that physicians should be able to practice medicine…
When a Medicare provider or supplier receives claims denials or an overpayment demand as a result of a Medicare audit, the decision whether and how to appeal the decision, or to simply repay the amount demanded by the Medicare contractor, is usually a business decision. In some cases, it may…
Medicare claims audits can be a complex and frustrating experience for healthcare providers who choose to accept Medicare. If claims are denied during the audit – and they nearly always are – the appeal process can itself take months or years and contains many strategic decisions for a provider to…
The number of Medicare payment suspensions issued by the Centers for Medicare & Medicaid Services (CMS) has grown in recent years. Although generally framed as a temporary and less severe sanction than an outright revocation of Medicare billing privileges, a suspension of Medicare payments can be just as devastating to…
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently updated its Work Plan, adding several new audits and reviews. The OIG Work Plan forecasts the projects that the OIG plans to implement over the foreseeable future. These new initiatives are a signal of which areas…
Simply put, Medicare rarely audits dentists because Medicare generally does not cover or pay for dentistry. However, doctors of dental surgery and doctors of dental medicine may perform far more complex surgical procedures than the examinations, cleanings, and fillings that are in the common perception of what a dentist does.…
On July 31, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year 2025 Physician Fee Schedule (PFS) Proposed Rule. Among other changes, the 2025 PFS Proposed Rule includes additional proposed changes to the so-called “60-day rule” regarding returning identified overpayments. Initially established by the 2010 Affordable…
The US Department of Justice (DOJ) recently filed its first criminal drug distribution prosecutions related to telemedicine prescribing through a digital health company. The indictments accused Done Global, Inc., its founder and CEO, its clinical president, and several other persons associated with the company of participating in a scheme to…