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Paul Zimmerman
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Showing 10 posts by Stacey L. Zill.

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Criminal Charges Brought in $1 Billion Alleged Medicare Fraud Scheme

If the June 2016 nationwide Medicare fraud takedown was not a sufficient indicator, today’s announcement that the U.S. Department of Justice (DOJ) has filed criminal charges against three Florida individuals alleging more than $1 billion in health care fraud, should make very clear that the federal government is cracking down on Medicare schemes.

The owner of more than 30 Miami-area skilled nursing and assisted living facilities, a hospital administrator and a physician’s assistant were charged with conspiracy, obstruction, money laundering and health care fraud involving numerous Miami-based health care providers. (Read More)

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Justice Department Announces Unprecedented National Health Care Fraud Takedown

In what is being billed as the largest coordinated Medicare fraud takedown in Justice Department history, Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell have announced an unprecedented nationwide sweep led by the Medicare Fraud Strike Force. The result is criminal and civil charges against 301 individuals for their alleged participation in health care fraud schemes involving approximately $900 million in false billings. This is but the latest example of the government increasing its scrutiny of Medicare reimbursement claims, and using its considerable leverage, and the media, to tighten the screws on health care providers. (Read More)

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Medicare Rolls Out Proposed Rule Altering Physician Payment Model

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule discussing how it intends to implement the Medicare physician payment reforms enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Congress voted to essentially scrap the existing Medicare physician payment formula, and transition to a new system focused on quality, value and accountability. The new model is ostensibly intended to close performance gaps in clinical care, safety, care coordination, patient and caregiver experience, population health and prevention, and affordable care. Hospitals, physicians and other providers, now have until June 27, 2016 to comment on the proposed rule. (View More)

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Federal Court Rejects Hospitals’ Challenge to Medicare Wage Rule 

In a decision with far-reaching implications within the health care industry, on February 22, 2016, a federal judge rejected a challenge to how Medicare reimbursement is adjusted based on local labor costs, dismissing assertions that regulators retroactively changed the applicable formula. Under the Medicare program, the government reimburses health care providers for certain expenses incurred in treating Medicare beneficiaries. The Medicare wage index reflects regional variations in hospital wage costs which is one factor used to determine the amount of reimbursement.  (Read More

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Jury Awards Aetna $37.4M in Medical Billing Fraud Case

A California jury in Aetna Life Insurance Company v. Bay Area Surgical Management LLC, et al., 1-12-CV-217943 (Superior Court of Santa Clara County), unanimously awarded Aetna Inc. over $37.4 million in damages, finding that a network of surgical centers overbilled Aetna, Inc. for out-of-network procedures by,  among other things, recruiting patients by approving waivers of co-pays and other fees.  (Read More)

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70,000 More Obstacles In The Way Of Getting Providers Paid

Providers devote countless hours and resources to obtain the training and understanding necessary to assign the proper diagnostic code to the services provided when submitting claims for reimbursement.  On October 1, 2015, the number of codes for doctors is increasing from 14,000 to 70,000, through the roll out of the latest version of the International Classification of Diseases, or ICD-10.  (Read more)

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Supreme Court Upholds Obamacare’s Federal Subsidies for Health Insurance

Supporters of the Obamacare are celebrating today as the Supreme Court in King v. Burwell rejected a lawsuit against the Affordable Care Act (ACA). In a 6-3 decision, the Supreme Court held that the federal government may continue to subsidize health insurance in those states that have not set up their own exchanges.  (Read more)

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Providers Cannot Sue State Officials Over Low Medicaid Reimbursements

On March 31, 2015, the U.S. Supreme Court in Armstrong v. Exceptional Child Ctr., Inc., 575 U.S. ___ (March 31, 2015) (No. 14-15), reversed the Ninth Circuit Court of Appeals’ decision that medical providers have a right to sue states to enjoin them from reimbursing providers at lower rates than provided in 42 U.S.C. §1396a(a)(30)(A) of the Medicaid Act (“Section 30(A)”), which provision requires state Medicaid plans to “assure that payments [to providers] are consistent with efficiency, economy, and quality of care.”  (Read more)

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California Patient Given Standing to Challenge Inflated Charges

In Sarun v. Dignity Health (2015) Cal App. 2d; B251767, an uninsured patient received emergency healthcare services from a hospital owned and operated by Dignity Health. Upon admission, the patient signed an agreement stating that patients without insurance must pay for full services, regardless of whether discounts apply. The patient subsequently received a balance of $23,487.90, which included an “uninsured discount.” The invoice explained that the patient may be eligible for further discounts though he did not apply for financial assistance.The patient did, however, make a partial payment toward the balance due.The patient subsequently filed suit against Dignity asserting claims for unfair business practices under Business and Professions Code section 17200 (UCL) and violation of the Consumers Legal Remedies Act (CLRA).The complaint alleged Dignity had failed to disclose that uninsured patients would have to pay substantially more than other patients for the same service, and the charges were unreasonable and grossly unfair. (Read more)

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Potential Problems with Waiving Patient Co-Pays

For a variety of reasons, healthcare providers will waive a commercial patient’s co-payment, co-insurance or deductible (collectively, “co-pay”) obligations. What many commercial providers may not realize is that the waiver of co-pays could result in their not being paid for services, or even expose them to fraud charges.  (Read More)