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Is Your MAO Effectively Capturing and Processing Medicare Advantage Risk Adjustment Data?

Effectively identifying and processing Medicare Advantage (MA) risk adjustment data is no simple matter – it requires extensive experience in data science, claims and encounter data analytics, actuarial science, CMS regulatory and sub-regulatory guidance, and up-to-date, HIPAA-compliant risk adjustment software platforms. Without these skills and technology, valuable MA risk adjustment data that would otherwise be submittable to CMS and generate increased revenues for your organization may be overlooked, ignored or...

Why Providers Need to Carefully Negotiate the Complex Payment and Penalty Provisions Under Shared Savings Agreements

 "Shared savings agreements" or "physician incentive plans" are agreements between provider groups and carriers or the government wherein bonus payments are paid, or penalties assessed, pursuant to a contractually agreed upon formula designed to measure quality-based performance over a given time period. As these relatively new agreements can be highly technical and the mechanics of the bonus calculation quite opaque (often by design), provider groups tend to take the bonus...

PHARMACY ALERT: New York OMIG Denies Pharmacies Enrollment in Medicaid Based on Private Payor Denials

Frier Levitt has been contacted by an alarming number of pharmacies who have had their applications for enrollment in the New York State Medicaid Program denied by the New York Office of the Medicaid Inspector General (OMIG) based on the pharmacies having, at one point or another, "failed to meet the criteria to be a participating provider" with certain private payors. By all appearances, this is an unconstitutional delegation of...

Frier Levitt Protects Medical Practice Against Putative Class Action Lawsuit for Alleged Protected Health Information (PHI) Disclosure

Frier Levitt successfully defended a medical practice in a lawsuit alleging various breaches including doctor-patient privilege, invasion of privacy, duty of care and NJ Consumer Fraud Act. The medical practice was sued along with a collection attorney for the alleged disclosure of PHI. Frier Levitt immediately filed a motion to dismiss on the basis that the information disclosed in a medical bill was not a violation of the doctor-patient privilege since...

Middle District of Florida Vacates $350 Million Dollar False Claims Act Judgment

A new opinion out of the Middle District of Florida illustrates a growing judicial trend that follows on the heels of the Supreme Court's landmark False Claims Act (FCA) decision in Universal Health Services, Inc. V. Escobar, 136 S.Ct. 1989 (2016), in which courts demand that relators demonstrate "meaningful and competent proof that the federal or the state government, if either or both had known of the disputed practices [alleged...