GAO Issues Report on Post-Payment Claims Reviews by CMS Contractors


The U.S. Government Accountability Office (GAO) recently issued a report entitled “Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Post-Payment Claims Reviews,” which analyzes the processes used by the Centers for Medicare & Medicaid Services (CMS) to avoid the duplication of post-payment claims reviews by its contractors. GAO’s report focused on the extent to which:

  • CMS has data to assess whether the CMS contractors conduct duplicative post-payment claims reviews and whether CMS ensures that these contractors do so only when appropriate;
  • CMS’ requirements for contractor correspondence with providers help ensure effective communication;
  • CMS uses quality assurance processes to ensure that contractors’ post-payment claims review decisions about whether claims were paid properly are appropriate; and
  • CMS has strategies for coordination of post-payment claims review activities among different types of contractors.

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New Federal Guidance on Reducing Medicaid Hospital Readmissions


The Agency for Healthcare Research and Quality (AHRQ) recently issued a guide to assist hospitals in reducing Medicaid patient readmissions. The AHRQ Hospital Guide to Reducing Medicaid Readmissions is the product of a two-year study which focused on identifying evidence-based strategies to reduce hospital readmissions and better serve the transitional care needs of the adult Medicaid population. According to AHRQ, the guide is the only federal tool that is specifically tailored to reducing readmissions in the adult Medicaid population.

Reducing hospital readmissions is a national priority for payers, providers, and policymakers. Over the past several years, the Centers for Medicare & Medicaid Services and the Center for Medicare & Medicaid Innovation have created various incentive programs, instituted financial penalties, and provided technical assistance to providers and communities with the goal of reducing hospital readmissions. The majority of these programs focus on the Medicare fee-for-service population, and use geriatric health service literature as the basis for the programs. Continue reading this entry

Georgia Composite Medical Board Issues New Telemedicine Rules


The Georgia Composite Medical Board enacted a new regulation governing the standards for telemedicine practice. The regulation, titled Practice Through Electronic or Other Such Means, is found under Georgia Comp. Rules and Regs. rule 360-3-.07 and is intended to establish the minimum standards of practice while providing treatment and/or consultation recommendations through the use of telemedicine.

Following two years of evaluation and discussions by the Board, the new rule went into effect May 3, 2014. Absent some minor changes, the rule is similar to the version originally contemplated by the Board. The rule offers some additional guidance on telemedicine practice in Georgia, although it does impose certain restrictions on telemedicine and telehealth in the State. Most notably, this is reflected in the rule establishing a default requirement of an in-person examination prior to a telemedicine encounter. Continue reading this entry

Veterans Access, Choice, and Accountability Act of 2014 Increases Graduate Medical Education Residency Positions


On August 7, President Barack Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014 (Act). While much press has been given to the Act’s increasing of access to private health care providers, increasing of recruitment of new physicians, and granting to the Secretary of the U.S. Department of Veterans Affairs (Secretary) more flexibility to terminate employees, less attention has been given to the Act’s requirement of the Secretary to increase the number of graduate medical education (GME) positions. Continue reading this entry

Eighth Circuit Dismisses Whistleblower's Suit Finding Facts Were Already Publicly Disclosed

CMS Releases Medicare Part B Supplier Billing and Payment Data

In an August 7, 2014 opinion, the Eighth Circuit upheld the dismissal of a whistleblower’s suit alleging that a number of pain pump device makers had violated the False Claims Act (FCA) by marketing their pain pumps for harmful off-label uses. United States ex rel. Paulos v. Stryker Corp. et al., 8th Cir., No. 13-2509, 8/7/14. The court unanimously found that the relator’s claims were barred under the FCA’s public disclosure bar and that the relator didn’t qualify as an original source under the FCA. In doing so, the Eighth Circuit adopted the majority view on this issue, in conflict with the Fourth Circuit. Continue reading this entry