Healthcare providers have long navigated the complex world of Medicare audits, working diligently to meet billing standards, document patient care thoroughly, and respond to regulatory oversight. What once existed as a strictly administrative process is now evolving into something far more serious—and punitive. Increasingly, providers are finding themselves at the intersection of standard Medicare audits
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April Fools’ Day and the Supreme Court: A 340B Comedy of Errors
Happy April Fools’ Day! In a move that shocked absolutely no one (except maybe a few overconfident pharmaceutical executives), the U.S. Supreme Court decided in December 2024 that it would not hear an appeal challenging an Arkansas law requiring drug companies to continue offering discounts through contract pharmacies. While pharmaceutical companies may have hoped for…
Welcome to the Circus: The State of Healthcare in America
Ladies and gentlemen, step right up! You’ve heard of Cirque du Soleil, you’ve seen the greatest show on Earth, but nothing—absolutely nothing—compares to the high-flying, death-defying, logic-defying spectacle that is the American healthcare system. And in this act, our fearless healthcare providers must navigate flaming hoops, balance on tightropes, and wrestle bureaucratic lions, all while…
Trump’s Deregulations…But Not in Health Care Fraud Detection!
As we don our green attire and raise a glass to St. Patrick’s Day, it’s worth pondering what luck—or lack thereof—a second Trump administration might bring for healthcare providers. While some may hope for the four-leaf clover of regulatory relief, history suggests that enforcement against healthcare fraud will remain as aggressive as ever. The Trump…
Challenging CMS’ Recoupment Before Full Adjudication: A Constitutional Perspective
The Centers for Medicare and Medicaid Services (CMS) has the authority to recoup alleged overpayments from healthcare providers before the full adjudication of an appeal. While this practice is legally sanctioned under federal regulations, it raises significant constitutional concerns, particularly with respect to due process under the Fifth Amendment. And quite frankly. I wish a…
HHS Eliminates Public Input on Key Policies: A Necessary Reform or a Dangerous Precedent?
In a significant shift in regulatory procedure, the Department of Health and Human Services (HHS) announced it will no longer use the notice-and-comment rulemaking process for policies related to agency management, public property, loans, grants, benefits, or contracts. This decision, announced by Secretary Robert F. Kennedy Jr., marks a break from 50 years of agency…
The Overzealous World of Medicare and Medicaid Provider Audits: When Auditors Get It Wrong
Medicare and Medicaid provider audits have become an increasingly contentious issue in the healthcare industry. While audits are essential to prevent fraud and ensure compliance, private auditing entities often act like overeager hall monitors, slapping fines on providers for imaginary infractions. These auditors are financially incentivized to find overpayments, which skews their judgment and results…
Medicare and Medicaid Audit Appeals: A Broken System in Desperate Need of Reform
The Medicare and Medicaid audit appeals process is a dysfunctional system that places an unjust burden on healthcare providers. The process is riddled with bias, inefficiencies, and financial hardship, all while being orchestrated by private contractors who often lack the expertise or incentive to conduct fair and accurate audits. Providers must unite, lobby, and demand…
2024: A Year in Review of Medicare Provider Wins
In 2024, several health care providers successfully defended against False Claims Act (FCA) lawsuits initiated by the government. These cases highlight the legal strategies and defenses that led to favorable outcomes for the providers. These three provider wins are exemplary; these were NOT the only provider wins in 2024 … just 3 examples.
Case Example…
Proactive Legal Representation in Medicaid and Medicare Audits: A Provider’s Best Defense
As a Medicaid and Medicare regulatory compliance litigator, I have found that most health care providers seek my counsel only after they receive a demand for repayment from the government. But what if you could prevent an accusation of owing overpayments? These demands, stemming from alleged overbillings, can be financially devastating, often reaching hundreds of…