Medicaid Compliance Strategies for Hospitals and Other Providers

Table of Contents

Health Reform Legislation

• OIG Chief Counsel: Fighting Medicaid Fraud Is Essential to Health Reform
• Experts Focus on Medicaid Fraud Prevention as Part of Health Reform
• Reform Would Bring Medicaid Changes; Anti-Fraud Focus Seems Destined to Pass
• Reform Law Includes Major Medicaid Integrity Provisions, Changes for Providers

Federal Medicaid Integrity Program

• CMS Medicaid Auditors Get to Work in 19 States, Starting With Easy, Obvious Errors
• Institutional Providers Must Prepare for Medicaid Integrity Program’s Action Year
• New N.Y. OMIG Work Plan, First MIC Audits Shed Light on Risk Areas for All Providers
• Prepare for Snags With MICs; State-Federal Interplay Will Keep Hospitals on Their Toes
• Providers to Feel Heat of Intense Medicaid Scrutiny; Kickbacks, Never Events, Also Hit
• Medicaid Providers Urged to Data-Mine to Help Them Answer MICs’ Audit Questions
• Hospitals Need More Guidance From CMS to Prepare for New MIC Audits, Expert Says
• Hospitals Are Starting to Lodge Complaints Over Early MIC Program Activity Snafus
• MICs Are Finding Few Recoveries, Sources Say; RACs Will Be ‘MICs on Testosterone’

State Initiatives

• More Medicaid Integrity Programs Use Provider Self-Audits; Hospitals Fear Burden
• Calif. Providers Investigated for Fraud Face Indefinite Suspensions
• New Medicaid Self-Disclosure Program Is ‘More Expansive’ Than OIG’s, New York Says
• N.Y. Requires Compliance Plan, Will Post Fraudulent Billers’ Names
• Providers Talk, OMIG Listens: State Eases Some Compliance Program Requirements
• N.Y. OMIG’s New Medicaid Fraud Efforts May Hinder Its Ability to Meet Recovery Goals
• N.J. OMIG Recovers $225M in First Year; Fla. Unit Gets New Tools
• Mich. Executive Order Creates Office to Battle Medicaid Fraud
• Some Medicaid Providers, Vendors See State False Claims Acts as Unnecessary
• Data Mining Thrives at State, Federal Levels; Providers Should Mine Their Claims
• Adverse Events Pose a Concern at State Level as More Refuse Billings, Levy Fines
• Calling All Whistleblowers: Indiana Reaches Out to Try to Stem Fraud

Medicaid Fraud Control Units

• CMS Advises States to Set Standards for Referrals to MFCUs
• Providers Urged to Take Multi-Step Risk Assessment in Face of Intense Scrutiny
• Nation’s 50 MFCUs Together Bring In $1.3 Billion in Fines
• Mo. MFCU Pulls in $81 Million in ’09; AG Pushes Use of Whistleblower Law
• N.M. Health Agency’s Practices Said to Hinder State’s MFCU Initiatives

False Claims Act – Quality Cases

• Hospitals Are Urged to Focus on Quality Initiatives as States Implement Measures
• Virginia Psych Facility for Boys Faces Claims, Quality Charges
• Nursing Homes Resolve Problems on Pain Management, Discharge Planning, Labs
• Nursing Homes Enter Guilty Plea, Pay Civil Settlement in Quality-of-Care Fraud Case
• National Dental Firm Agrees to Pay $24 Million in Medicaid Fraud Case
• FCA Suit Targets Providers, Not Drug Firms, in Novel Off-Label Use Case
• Civil Case Alleges That Hospital, Physician Harmed Cardiac Patients

Major Medicaid Fraud Cases

• N.Y. Accuses Seven Hospitals of $50 Million in Medicaid Fraud
• WellCare Settles Federal Medicaid Probe via DPA, Large Penalties
• Experts Indicate UMDNJ Settlement May Be the Tip of the Legal Iceberg for Both Sides
• Axed Medicaid Provider Says System Works Against Firms Like Hers
• $47 Million Case Shows Complexity of Medicaid Fraud Enforcement
• Grady ‘Maximized Payments’ Before, Now Must Repay Medicaid $20M
• N.Y. HHAs Pay $24 Million for Not Checking Employee Credentials
• Hospital Settles Case of Alleged Medicaid Stark Law Violations

Written By

This book was written by the editorial staff of AIS.

Written For

• Hospitals, health systems and other providers
• State government health care officials
• Managed care companies
• Other facilities

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