NABIP - Arizona Chapter’s Post

The prevalence of healthcare fraud underscores the urgent need for comprehensive strategies to combat deceptive practices and protect public resources. Our latest blog showcases top fraud, waste, and abuse cases from Q4 2023. An example of just a few cases from this past quarter: ▫️ A Texas ophthalmologist faces charges for $402 million in alleged false claims ▫️ A diagnostic laboratory supposedly gave kickbacks to physicians under the guise of ownership interests in the laboratory ▫️ A New York cardiologist purportedly billed Medicare, Medicaid, and private insurers over $100 million using fake patient records Read more in our blog: https://bit.ly/49vKVNY #FWA #healthcare #HealthPlans

Noah Tong’s great article in Fierce Healthcare on DOJ’s discussion of Medicare Advantage and risk adjustmemt in the Department’s year end report on 2023 False Claims Act recoveries is linked below. I’m quoted. #medicareadvantage #fca #healthcarecompliance #healthcarefraud

The prevalence of healthcare fraud underscores the urgent need for comprehensive strategies to combat deceptive practices and protect public resources. Our latest blog showcases top fraud, waste, and abuse cases from Q4 2023. An example of just a few cases from this past quarter: ▫️ A Texas ophthalmologist faces charges for $402 million in alleged false claims ▫️ A diagnostic laboratory supposedly gave kickbacks to physicians under the guise of ownership interests in the laboratory ▫️ A New York cardiologist purportedly billed Medicare, Medicaid, and private insurers over $100 million using fake patient records Read more in our blog: https://bit.ly/49vKVNY #FWA #healthcare #HealthPlans

ReNew Health to Pay $7 Million to Settle First-of-its-Kind COVID-19 False Claims Act Case — PRBuzz.co — Zimmerman Reed announces #7 #million settlement for the #US and #State of #California in a first-of-its #kind #False Claims #Act #case involving a #COVID19 waiver program. MINNEAPOLIS, Minn., #April #29 #2024 Zimmerman Reed announced #today that the #United #States and the State of California reached a $7 million settlement with ReNew #Health #Group LLC, #renew Health #Consulting #Services LLC, and its owner-CEO and its COO to resolve False Claims Act allegations filed by Zimmerman Reed's whistleblower #clients ReNew Health, the #owner and #operator of dozens of #nursing facilities throughout California, allegedly submitted millions of dollars of fraudulent claims to Medicare and California Medicaid since March 2020 under a scheme involving a COVID-19 waiver program. "This case emphasizes the vital contribution that whistleblowers can make in exposing healthcare fraud," said June Hoidal, chair of Zimmerman Reed's Whistleblower practice. "The courage of our clients who reported improper Medicare and Medicaid claims was instrumental in bringing this case to light and securing a just result." "Along with the whistleblowers who uncovered these wrongdoings, we commend the United States and the State of California for thoroughly investigating these allegations and bringing this case to resolution," said Chuck Toomajian, counsel for the whistleblowers and a member of Zimmerman Reed's Whistleblower practice. "Their diligence resulted in recovering substantial overpayments and is critical in protecting taxpayers and government health care programs against these schemes." To free up hospital beds during the COVID-19 crisis, the Centers for Medicare and Medicaid Services

Today is June 5—or 6/5. 65 is a special number for the #Medicare program. That’s the age at which most Americans become eligible for Medicare. And that’s why this week is Medicare Fraud Prevention Week!    Medicare has done tremendous good, providing health insurance to hundreds of millions of senior and disabled Americans since 1965 (see that number again?!). Medicare’s passage was key to certain aspects of the civil rights movement, like the desegregation of hospitals and increasing access to healthcare for communities of color. Since 1965, the poverty rate amongst American seniors has fallen by nearly two thirds, while life expectancy has increased by a decade.   However, with nearly half a trillion dollars in annual spending, unscrupulous actors are drawn to Medicare like moths to a flame. A recent Senate committee report estimated that Medicare loses about $60 billion a year to fraud. Fraud against the program comes in many shapes and sizes, ranging from billing for services not provided or tainted by kickbacks, to medically unnecessary treatments, such as providing surgeries to perfectly healthy people. #Whistleblowers have been essential to combatting and deterring that fraud, promoting patient safety, and recouping billions of taxpayer dollars. Read more about types of Medicare fraud by clicking below:

Urgent Update: Mass Medicare Data Breach - What You Need to Know Join Moné Swann, CEO, and Alicia Alcaino, COO, from BIVX Wealth & Insurance Solutions as they discuss the recent mass Medicare data breach with experts from the Centers for Medicare & Medicaid Services (CMS). In this critical session, we'll delve into the details of the breach, its impact on beneficiaries, and important steps to safeguard your information. Learn about the immediate actions Medicare is taking to secure data and what you can do to protect yourself from potential fraud. Don't miss this essential update to stay informed and secure. We are Live every Thursday, at 11:00 AM PST/2:00 PM EST on our Secure65healthplans YouTube platform. Be part of the future. Be part of something big. #AEP #HereToHelp #StayUpdated #Community #LoveandTrustTour #HealthFirst #MedicareMatters #Medicare #MedicareEnrollment #Beneficiary #ANOC #Medical #Healthinsurance #Medigap #AEP #Medicare2024Updates #Annualnoticeofchange #Agent #Broker #Protection #Coverage #Insurance #Support #Secure65Healthplans #BIVXWealth

Hey Y'all! It's time for #FridayFraudsters!! This release highlights the conviction of a physician fraudulent billing for hospice services. Hospice services are for patients that are in the end stages of an incurable disease. It aims to ensure that they are comfortable and able to live the last days of their lives as fully as possible. The physician was the medical director of several hospice companies and he fraudulently certified that Medicare patients had terminal illnesses that they didn't have to the company could bill for hospice services. This physician had more hospice claims paid by Medicare than any other provider in the nation. I know somebody has to be first, but if your provider is first, s/he will probably be looked at to ensure compliance. The physician was convicted of one count of conspiracy to commit health care fraud and four counts of health care fraud and will be sentenced on May 28th. He faces a maximum of 50 years in prison. Please share/repost if you feel others will others will benefit from this information. #doj #healthcarefraud #healthcare #medical #Medicare #medicalcoding #medicalbilling #practicemanagement #compliance #healthcarecompliance #chcs #FridayFraudsters https://lnkd.in/exWb4gRh

False Claims Act (FCA) Settlements nearing $2.0 Bn in 2023 * FCA Purpose: The FCA penalizes those who falsely claim money from or fail to pay funds to the U.S. government. * Focus on Healthcare Fraud: Regulators utilize the FCA to target healthcare fraud effectively. * Medicare Advantage Program: DOJ highlighted actions related to the Medicare Advantage (MA) program, where private insurers manage beneficiaries' care, covering over half of the eligible Medicare population. * Cost Escalation: MA program costs have increased substantially, with the government potentially paying $88 billion more this year due to MA plans attracting healthier beneficiaries and aggressive coding for increased reimbursement. * Upcoding Cases: Examples include Cigna and Martin’s Point Health Care, which paid settlements for submitting inaccurate diagnosis codes to boost Medicare payments. More insights: https://lnkd.in/gCsmkrRu

New steps to prevent AOR theft and protect customers from unauthorized ACA Marketplace plan changes. What’s your organization preparing to do? Have you considered how this may help? What steps will EDE’s enact? Thoughts? #aca #aor #Ppaca #marketplace #insurance #compliance #operations #broker #leadgeneration #fpl #agent #medicare #ffm #healthsherpa #cms #oep #obamacare #healthcare #healthinsurance #taxcredit

With the esteemed guidance of Shri Debasish Panda ji, IRDA unveiled ground-breaking reforms in their latest circular dated 29th May 2024. In a significant stride towards their vision of "Insurance for All," IRDA introduced a comprehensive health policy framework. This initiative offers consumers an array of options including coverage for chronic/pre-existing ailments, OPD services, all age groups, disabilities, and various professions. Prioritizing the policyholder's experience during claims, IRDA has underscored the importance of quick turnaround times for cashless transactions, rigorous claims review procedures to ensure rightful approval of claims, and the establishment of a robust grievance redressal system. I had the chance to share my thoughts on these reforms on ET Now Swades. Here are some key highlights from the recent IRDA Circular: Coverages: Comprehensive coverage for all age groups. Inclusion of pre-existing chronic ailments. OPD and domiciliary coverage. Coverage for HIV, mental ailments, and disabilities. All systems of medicine to be covered. Coverage aligned with various laws.   Claims Cashless: Cashless services available in all hospital. Initial approval turnaround time of 1 hour. Final approval within 3 hours; beyond this, any additional costs to be covered by the insurer. In case of policyholder's death, instant approval and prompt release of the deceased's body. Rejections to be reviewed by PMC or CRC before a denial decision.   Policy Renewal and NCB: Renewal can only be denied in cases of fraud or data misrepresentation. No Claim Bonus can be used to increase sum insured or as a premium discount. 30-day free-look period and policy cancellation with refund policies in place. Grace period of up to 30 days for premium payment in installment-based policies. Migration options with continuity benefits. Policies cannot be contested after a 60-month moratorium period.   Grievance Redressal: In cases where insurers fail to comply with Ombudsman decisions, a penalty of INR 5000 per day is imposed. #healthinsurance #insurance #alliance #irda