HHS Departmental Appeals Board (DAB) Appeals (June 15, 2023): The Department of Health and Human Services (HHS) is enormous, employing more than 80,000 individuals[1] who work in a dozen operating divisions and an even greater number of independent offices that report directly to the Office of the Secretary.[2] One of these independent offices is the HHS Departmental Appeals Board (DAB or Board). The DAB has been designed to provide an impartial, independent review of disputed agency decisions under a wide variety of statutory and regulatory provisions.[3] This article examines the DAB in mo ..read more

COVID-19 Vaccine Mandate Update (June 20, 2023): In response to the recent public health crises, the Centers for Medicare & Medicaid Services (CMS) first implemented a vaccine mandate for healthcare providers in late 2021. This policy was an effort to safeguard the vulnerable populations served by healthcare workers. This directive required that all healthcare workers, volunteers and third-party contractors working in facilities participating in Federal health benefit plans be vaccinated against COVID-19. While supporters of the mandate viewed it as a necessary step to protect the public ..read more

Medicare Advantage SIU Audits and Investigations are More Prevalent Than Ever Author: Ashley Morgan, Annabella Denzel (April 5, 2023): In the sphere of healthcare compliance, providers must manage audits coming from every possible authority whether it be from public agencies, a private payor, or other third-party authorities. CMS has announced that the FY 2022 fee-for-service improper payment rate was 7.46%.[1] While this is a slight increase in the error rate from the past two years (6.27% and 6.26% respectively), it is still a significant improvement over a decade high of 12.09% in 2014 ..read more

Medicare Exclusion Risks: Employing Excluded Individuals Can Result in Significant Administrative, Civil and / or Criminal Liabilities (May 8, 2023): One of the most severe administrative sanctions available under the Social Security Act stems from the authority of the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS)[1] to “exclude” individuals and entities from participating in Federal health care programs.[2] While the Centers for Medicare and Medicaid Services (CMS) can revoke a provider's billing privileges, it has no authority to impose or decli ..read more

Health Care Provider Risks When Ordering and Billing Chelation Therapy Services (January 25, 2024): Although chelation therapy[1] has played an important role in mainstream medicine for many years,[2] it is still considered by many clinicians and regulators to fall within the category of "Complementary and Alternative Medicine." Proponents of chelation therapy in alternative medicine practices have supported its use in treating Alzheimer’s disease,[3] Parkinson’s disease, multiple sclerosis,[4] autism, and several other medical conditions.[5] One area in particular, cardiovascular disease, h ..read more

The OPM Debarment Process – Responding to an FEHBP Debarment or Suspension Action in 2024 Author: Ashley Morgan, Christin Thompson (December 20, 2023): Most health care providers and suppliers are familiar with the fact that as a participating provider in the Medicare and / or Medicaid programs, certain criminal convictions, adverse licensure actions, and various types of prohibited conduct may subject the provider to exclusion from participation in Federal health care programs[1] by the Department of Health and Human Services, Office of Inspector General (HHS OIG).[2] However, they may no ..read more

Hospice Audit and Investigative Actions are Expected to Rise in 2024 (November 20, 2023): Medicare, Medicaid, and most private insurance plans cover hospice care and related services. To be eligible for hospice care,1 a patient must be certified as terminally ill and have a life expectancy of six months or less.  In recent years, the hospice industry has exponentially grown, and the number of Federal, State and Special Investigative Unit (SIU) audits and investigations have similarly increased. Private equity firms have entered the industry—now estimated at 16% of all hospice providers ..read more

AI in Medical Billing: A Benefit or a Compliance Risk? Author: Christin Thompson, Annabella Denzel (October 10, 2023): In terms of revenues and expenses, health care providers and suppliers have repeatedly faced two unfortunate realities: (1) Reimbursement rates are shrinking, and (2) they are constantly being saddled with additional unfunded mandates (for example, HIPAA compliance, OSHA requirements, compliance obligations, etc. Coupled with ordinary practice expenses, many health care providers are finding it increasingly difficult to remain profitable.[1] Regardless of whether billing i ..read more

Texas HHSC-OIG is Ramping-Up its Investigations of Medicaid Pediatric Telemedicine Claims (June 27, 2023): In the State of Texas, Medicaid plays a significant role in providing healthcare services to a large portion of the population. With more than 5.9 million[1] Texans (approximately 18.9% of the current population[2]) enrolled in Medicaid, it is an essential program for qualifying low-income citizens. In Texas, Medicaid costs taxpayers over $40 billion. Federal and industry authorities estimate that fraud [3] comprises up to 10% of the costs of the Medicaid program, making Medicaid fraud ..read more

Medicare Advantage Plans are Aggressively Denying Claims – Administrative Appeals are Growing (May 25, 2023): According to the latest data released by the Centers for Medicare and Medicaid Services (CMS), beneficiaries participating in Medicare Advantage[1] plans now surpass those enrolled in original Medicare plans. Slightly more than one-half[2] of the 59.82 million Medicare beneficiaries now eligible for coverage have signed up for one of the 5,261 Medicare Advantage payor plan options offered by 182[3] private plans around the country.[4] There are a number of reasons why Medicare Advant ..read more