Medicare and Medicaid audits are an inevitable part of the healthcare landscape. With the increasing demand for healthcare services and a growing focus on reducing federal spending, providers can find themselves under scrutiny for alleged overpayments. These audits, while essential
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Ohio Decides to Raise Medicaid Reimbursement Rates. Now, If Only Other States Followed Suit…
Ohio, in its infinite wisdom, has decided to take a bold step forward in healthcare by raising its Medicaid reimbursement rates. And when I say “bold,” I mean “a historic, mind-blowing $3.4 billion per year” kind of bold. That’s right—Ohio,
Scrutiny for Reactivating Medicare Providers and Reimbursement Rates for “Swing Beds”
Picture this: you’re a healthcare provider who’s been out of the Medicare game for a while, maybe took a little break to recharge, and now you’re ready to dive back into the waters of reimbursement. Enter the Centers for Medicare
A Major Step Toward Tackling Small Dollar Medicare and Medicaid Fraud
Many smaller providers believe that they are too small for the government to investigate them. Small providers may think that the small amount that they bill Medicare and Medicaid would not catch the governments’ eyes. Which may or may not
Medicare and Medicaid Provider Audits: Are You on the Naughty List?
As the holiday season rolls in, so too does the festive spirit of Medicare and Medicaid provider audits. Imagine this: the snow is gently falling, Christmas lights twinkle on every house, and in the midst of the holiday cheer, a
2025 and AI: The Future of Medicare and Medicaid Provider Audits
The Medicare and Medicaid provider auditing process is about to get its own makeover in 2025. I am talking about artificial intelligence, which will be more accurate than our auditors pre-2025. The Medicare provider auditing process has evolved significantly in
CMS Policies: One Size Does Not Fit All
This past Friday I drove to Avery County, which is in western NC to provide a day of pro bono services for the victims of Hurricane Helene. Apparently, FEMA is denying applications based on flooding not being covered. The NC
RAC Overpayment Allegations Versus FCA Accusations: The Importance of Whom and Scienter
I am so happy to be here. For those of you who watched the live version of last week’s Monitor Monday, I suffered a seizure during my segment. I am so thankful to Dr. Hirsh for recognizing the signs and
Health Care Executives: Does Your D&O Policy Protect You Enough?
Today I want to talk about Directors and Officers’ Liability Insurance (D&O), which becomes extremely important if a relator alleges your hospital or health care company billed Medicare or Medicaid for false claims. False claims accusations in qui tam lawsuits
The End of Chevron Deference: How Loper Bright Could Help Defendants Challenge Materiality in False Claims Act Cases
The U.S. Supreme Court’s decision in Loper Bright Enterprises v. Raimondo marked a pivotal shift in administrative law by ending the longstanding doctrine of Chevron deference. This change, which limited judicial scrutiny of agency interpretations of ambiguous statutes, has significant