In August, we discussed an OIG audit, which revealed that Medicaid providers who were terminated for cause were often able to still participate in other state Medicaid programs. Through this audit, OIG discovered that many providers were able to take advantage of a particular exclusion loophole within the Medicaid Managed Care program. Specifically, OIG discovered… more>>
In February, we reported that the Michigan Attorney General secured a racketeering and health care fraud conviction against an excluded Michigan podiatrist. The podiatrist participated in an elaborate health care fraud scheme with another Michigan provider. In early July, the Michigan Attorney General successfully convicted the doctor who knew or should have known that the… more>>
In late July, a federal district court in Pennsylvania joined in the flurry of False Claims Act (FCA) decisions. These decisions further interpreted the ACA’s amendments to the law. The court in United States ex rel. Boise v. Cephalon, Inc. considered two important issues. The issues regarded when a party has an obligation to pay… more>>
OIG has been busy cracking down on providers who employ or contract with excluded persons or contractors. In fact, by the end of July OIG settled 27 exclusion violation cases through investigations or self-disclosures. By way of reminder, there were 60 enforcement actions related to OIG exclusion violations in 2014. Following is our 2015 mid-year… more>>
The owner of a New Jersey ambulance company was indicted for health care fraud in mid-August of 2015. The owner was excluded from participation in the federal health care programs after being convicted of defrauding New Jersey health care programs in 2003. This is just the latest in a steady stream of health care… more>>
Our experts at Exclusion Screening, LLC maintain fact sheets that contain the screening requirements for providers in every state, including those states that do not currently maintain a separate excluded or terminated provider list. However, Medicaid participation and adherence to exclusion screening requirements does not stop with the fifty states. United States territories like Puerto… more>>
The Affordable Care Act (ACA) creates a 60‑day window to report and return overpayments from Medicare or Medicaid after the date on which the overpayments were identified. If the overpayments are not returned within 60 days, then they can become false claims. Though this has been the law since 2010, we are just now seeing how… more>>
OIG Audit Findings In a recently released audit, the OIG found that despite the ACA requirement that states terminate Medicaid providers already terminated in another state, 12% of providers already terminated for cause in 2011 in one state (295 out of a sample of 2,539) were still participating in other state Medicaid programs as… more>>
DOJ Pursuing Action on Two Separate OIG Exclusion Violations The U.S. Attorney’s Office in Philadelphia filed a False Claims Act case last week based primarily on OIG exclusion violations. The complaint alleges that the defendant filed several documents concealing his exclusion and his role in Mental Health Clinics ostensibly run by his wife. Medicare and Medicaid… more>>
Assistant Inspector General Testifies before Congress Ann Maxwell, the Assistant Inspector General for Evaluation and Inspections, recently testified before Congress. She argued that the Centers for Medicare and Medicaid Services (CMS) had not exercised “sufficient oversight of plan sponsors,” and “needed to strengthen its controls” in order to prevent payments for drugs “to providers excluded… more>>