Following the release of an April 16, 2021 HHS Office of Inspector General (“OIG”) report entitled “Medicare Advantage Compliance Audit of Diagnosis Codes that Humana, Inc. (Contract H1036) Submitted to CMS” (the “OIG Report”), headlines... Read More
All types of single and multi-specialty medical practice groups | Articles | Healthcare | Healthcare Law | Healthcare Litigation | Medicare and Insurance Audits | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News | Value Based Care

Earlier this week following a three-day bench trial, the owner of, and a licensed mental health counselor at, a Tallahassee-based counseling center, were found guilty of health care fraud conspiracy, health care fraud, and aggravated identity theft.... Read More
Articles | Healthcare | Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News | White Collar Criminal Defense & Government Investigations

The “law” applicable to drug reimbursement encompasses an array of laws across 50 states, the territories, and the federal government. These laws and regulations determine what a “Plan Sponsor” (such as an insurance plan, State Medicaid... Read More
Articles | Community, Retail Pharmacies | Life Sciences | Maximum Allowable Cost Pricing & Appeals | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | News | Pharmacy Law | Plan Sponsor PBM Contract Services

One: According to Supreme Court Justice Antonin Scalia, “Administrative Law is not for sissies.” Medicare rules in general, and the appeals process, in particular, are codified in a complex body of regulations known as administrative law.... Read More
Articles | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

The U.S. Attorney’s Office, Western District of Louisiana, recently announced that the owner and operator of the Monroe-based Specialty Drug Testing, LLC (“Specialty”) was indicted by a Federal grand jury for violating the Federal... Read More
Healthcare | Healthcare Law | Hospitals and Healthcare Systems | Laboratories | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

The Center for Medicare & Medicaid Services (CMS) released a moratorium on March 10, 2020 directing Medicare Advantage Organizations (MAOs), Medicare Part D Sponsors (Sponsors), Medicare-Medicaid Plans (Plans), and consequently, pharmacy... Read More
Articles | COVID-19 Resources | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals | Pharmacy Law

On March 6, 2020 the Centers for Medicare & Medicaid Services (CMS) issued frequently asked questions (FAQs) and answers for healthcare providers and supplemented a February Public Health News Alert regarding Medicare payment for laboratory... Read More
Articles | COVID-19 Resources | Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

Acting on Executive Order #13890, "Protecting and Improving Medicare for Our Nation's Seniors," the Centers for Medicare & Medicaid Services ("CMS") will consider new regulations designed to eliminate the regulatory barriers that constrain... Read More
Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

While some may still question whether it is true that "one bad apple can spoil the bunch," when it comes to doctors, group practices, and Medicare, this well-known adage is true. Surprisingly, there are instances when a single doctor's conduct, can... Read More
Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

In recent months, Medicare Advantage Organizations (MA Organizations) across the country have been on a network termination binge – often terminating physicians without sufficient (or sometimes any) notice and opportunity to appeal. These... Read More
Healthcare Law | Medicare, Medicaid, and Other Commercial Payor Audits & Appeals