A couple of recent large-scale enforcement actions suggest that the U.S. Department of Justice (DOJ) may be placing increased emphasis on targeting black market prescription drug diversion. This is when pharmaceutical...more
3/5/2025
/ DEA ,
Department of Justice (DOJ) ,
Distributors ,
Enforcement Actions ,
Healthcare Fraud ,
Medicaid ,
Medicare ,
Pharmaceutical Industry ,
Pharmacies ,
Prescription Drugs ,
White Collar Crimes
Lots of health care service providers find themselves in the position of needing to file a Medicare appeal. Despite the systematic nature of modern Medicare billing, wrongful denials remain common, and errors during Medicare...more
3/26/2024
/ Auditors ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Denial of Insurance Coverage ,
Health Care Providers ,
Medicare ,
Medicare Appeals ,
OMHA ,
Physician Medicare Reimbursements ,
Redeterminations ,
Reimbursements
According to the National Health Care Anti-Fraud Association, an estimated $100 billion is lost to Medicare fraud every single year in the U.S., with overtaxed law enforcement agencies relying heavily on whistleblowers to...more
Government agency audits focused on Medicare, Medicaid, and pharmacy benefit manager (PBM) compliance can result in substantial losses for pharmacies. Each pharmacy is audited the same way it is done with other similarly...more
Yesterday, the U.S. Department of Justice (DOJ) announced that it has filed charges against 36 defendants in relation to an alleged health care fraud scheme that resulted in approximately $1.2 billion in fraudulent payments....more
7/21/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Criminal Prosecution ,
Department of Justice (DOJ) ,
Enforcement Actions ,
FBI ,
Health Care Providers ,
Healthcare Fraud ,
Kickbacks ,
Medicare ,
Medicare Beneficiaries ,
Physician Medicare Reimbursements ,
Physicians ,
Telehealth ,
Telemarketing ,
Telemedicine
The Centers for Medicare and Medicaid Services (CMS) and its audit contractors have recently increased their use of Targeted Probe and Educate (TPE) audits to target providers suspected of improperly billing Medicare. While...more
6/21/2022
/ Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Criminal Investigations ,
Health Care Providers ,
Healthcare Fraud ,
Medical Billing Codes ,
Medical Records ,
Medicare ,
Medicare Administrative Contractors (MAC) ,
Medicare Appeals ,
Medicare Fraud ,
Penalties ,
Physicians ,
Targeted Probe and Education (TPE) audit
For diabetic patients and the doctors who treat them, blood sugar levels are crucially important. However, the traditional method of testing one’s blood sugar with a pin-prick is undesirable for many patients, which leads to...more
The federal government has recently made clear its intention to go after healthcare providers who provide amniotic injections to certain Medicare and Medicaid recipients. Over recent years, the federal government has...more
10/26/2021
/ Anti-Kickback Statute ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Civil Investigation Demand ,
Civil Liability ,
Criminal Liability ,
Defense Strategies ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Government Investigations ,
Health Care Providers ,
Healthcare Fraud ,
Medicaid ,
Medicare ,
Physicians ,
Stark Law
Cardiovascular stress testing to diagnose patients with coronary artery disease (CAD) and other related types of conditions can be a highly-effective tool in many cases. In fact, many cardiologists routinely recommend stress...more
8/24/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
Documentation ,
False Billing ,
Health Care Providers ,
Investigations ,
Local Coverage Determinations (LCDs) ,
Medical Necessity ,
Medicare ,
Medicare Fraud ,
OIG ,
Policies and Procedures ,
Stress Tests
The Centers for Medicare and Medicaid Services (CMS) and U.S. Department of Justice (DOJ) are scrutinizing health care providers’ Medicare billings for amniotic injections. These injections are only eligible for Medicare...more
8/17/2021
/ Anti-Kickback Statute ,
Billing ,
Centers for Medicare & Medicaid Services (CMS) ,
Civil Investigation Demand ,
Department of Justice (DOJ) ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Fraud ,
Medicare ,
Medicare Fraud
Durable medical equipment (DME) is particularly important for many Medicare beneficiaries. However, companies that manufacture and sell DME need to be careful because there are strict federal regulations outlining almost...more
7/28/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Chief Compliance Officers ,
Civil Liability ,
Compliance ,
Compliance Commitees ,
Corrective Action Plans (CAPs) ,
Criminal Liability ,
Department of Health and Human Services (HHS) ,
Disciplinary Proceedings ,
Durable Medical Equipment ,
Employee Training ,
Health Care Providers ,
Healthcare Fraud ,
Medicaid ,
Medicare ,
OIG ,
Physicians ,
Policies and Procedures ,
Standard of Conduct ,
TRICARE
Zone Program Integrity Contractors (ZPICs) and Unified Program Integrity Contractors (UPICs) are federal contractors who work under the direction of the Centers for Medicare and Medicaid Services (CMS) to uncover fraudulent...more
5/25/2021
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Defense Strategies ,
Department of Justice (DOJ) ,
Enforcement Actions ,
False Billing ,
Health Care Providers ,
Healthcare Fraud ,
Medicare ,
Overpayment ,
Provider Payments ,
Underpayment ,
Zone Program Integrity Contractors (ZPICs)
Medicare pays billions of dollars in fraudulently billed claims each year. To recoup as many fraudulent reimbursements as possible, the Centers for Medicare and Medicaid Services (CMS) relies on various enforcement...more
4/6/2021
/ Centers for Medicare & Medicaid Services (CMS) ,
Defense Strategies ,
Documentation ,
False Billing ,
Fraud and Abuse ,
Health Care Providers ,
Healthcare Fraud ,
MACs ,
Medicare ,
Physicians ,
Recovery Audit Contractors (RACs)
The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) is tasked with combating fraud under Medicare, Medicaid, and other federally funded healthcare programs. ...more
3/10/2021
/ Clinical Laboratories ,
Compliance ,
Compliance Monitoring ,
Corrective Action Plans (CAPs) ,
Dentists ,
Department of Health and Human Services (HHS) ,
Health Care Providers ,
Healthcare Facilities ,
Healthcare Fraud ,
Hospitals ,
Internal Audit Functions ,
Medicaid ,
Medical Billing Codes ,
Medicare ,
Nursing Homes ,
OIG ,
Pharmacies ,
Physicians ,
Policies and Procedures
Most health care providers have at least a basic understanding of the Anti-Kickback Statute. This federal law prohibits providers from offering, paying, soliciting, or accepting any form of “remuneration” for patient...more
12/11/2020
/ Anti-Kickback Statute ,
Civil Liability ,
Clinical Laboratories ,
Criminal Liability ,
Criminal Penalties ,
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Facilities ,
Medicaid ,
Medicare ,
Medicare Part D ,
Noncompliance ,
Patient Referrals ,
Physicians ,
Policies and Procedures ,
Stark Law
Compliance is a key aspect of operating a successful pharmacy in the United States. This is true for pharmacies that bill federal healthcare benefit programs (i.e. Medicare, Medicaid, and Tricare) and private payors, and it...more
8/3/2020
/ Americans with Disabilities Act (ADA) ,
Cannabidiol (CBD) oil ,
Compliance ,
Controlled Substances Act ,
DEA ,
DSCSA ,
Federal Trade Commission (FTC) ,
GINA ,
Health Insurance ,
Medicaid ,
Medical Billing Codes ,
Medicare ,
Pharmacies ,
Pharmacist ,
Pharmacy Benefit Manager (PBM) ,
Policies and Procedures ,
Risk Mitigation ,
TRICARE