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Jail for False Health Insurance Claims – Health Insurance Fraud Conviction Stands

Because Medicare and Medicaid pay health care providers promptly and without any inquiry into the probity of the claim health insurance fraud is a fairly easy crime to commit with little chance of being arrested or convicted. Perhaps that is the reason why the extent of health insurance fraud is counted...

Staying Covered: How Immigrants Have Prolonged the Solvency of One of Medicare’s Key Trust Funds and Subsidized Care for U.S. Seniors

"The Partnership for a New American Economy’s new report, Staying Covered: How Immigrants Have Prolonged the Solvency of One of Medicare’s Key Trust Funds and Subsidized Care for U.S. Seniors , shows that immigrants are key contributors to Medicare’s Hospital Insurance Trust Fund...

Foley & Lardner LLP: 8th Circuit Dismisses Whistleblower's Suit Finding Facts Were Already Publicly Disclosed

By Jacqueline N. Acosta 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...

Norton Rose Fulbright: Physicians Payments Sunshine Act Data 33 Percent Unpublishable, Penalties Next?

By Benjamin Koplin , Selina Coleman and R. Jeffrey Layne Despite extending the dispute-and-resolution deadline to account for the days that the Centers for Medicare & Medicaid Services (CMS) pulled down the reporting system, the public Physician Payments Sunshine Act website is still expected...

Norton Rose Fulbright: CMS Offers Settlement Of Inpatient RAC Denials

By Mark Faccenda On August 29, 2014, the Centers for Medicare and Medicaid Services (“ CMS ”) announced that certain providers with pending appeals of specified inpatient-status claims denied by Medicare contractors may elect to receive partial payment on those claims in exchange for the...

Thank Heaven for Little Girls….. and “Clean Claims” in Delaware

This comes to us from Christopher Logullo of Chrissinger & Baumberger, also known as in-house counsel for Liberty Mutual. I had commented recently about how I love hearing from counsel regarding their cases and more importantly, their take on the Board’s ruling and for a second time this week...

Opioids – The Grand Debate

An examination of ACOEM’s newly revised opioid practice guidelines for treatment of pain By Robert G. Rassp, Esq. We hate statistics but policymakers can’t live without them. For example, 100 million residents of the United States have chronic pain according to a 2011 report from...

Workers’ Compensation and Its Secondary Payers: Medicare and Medicaid

Last November I had the pleasure of participating in a panel with two more eminently qualified folks—Jennifer C. Jordan of MEDVAL, LLC and Tim Nay at Nay & Friedenberg —about Medicare Secondary Payer (MSP) compliance at the 23rd Annual National Workers’ Compensation and Disability...

California Official Medical Fee Schedule: The Death of the Extraordinary Circumstances Exception Post-2004

In what appears to be a case of first impression, the WCAB panel in Jaime Torres Tavera v. T and P Farms, Zenith Insurance Company , 2015 Cal. Wrk. Comp. P.D. LEXIS --, reversed the WCJ’s finding and held instead that the extraordinary circumstances exception to the fee schedule applies only to...

Medical Expert Says U.S. Health Industry Often Guilty of “Overkill”

Significant percentage of medical care procedures is unnecessary Much has been written about the explosion of health care costs in the workers’ compensation system. Indeed, most experts agree that medical care expenses now represent more than 60 cents out of every benefit dollar provided to...

DLA Piper Health Systems Alert: MACRA: 3 Compliance Implications For Medicare Providers

By: Karen Nelson Much has been written about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its repeal of the Sustainable Growth Rate formula for physician compensation and the potential gainsharing safe harbor. But the Act also includes certain Medicare program integrity provisions...

Barnes & Thornburg: CMS Releases Physician-Level Payment Data Totaling More Than $90 Billion in Medicare Reimbursements for 2013

By Jessica Talati On June 1, the Centers for Medicare & Medicaid Services (CMS) released its second annual installment of Medicare reimbursement data for physicians and other practitioners. The data set contains records for more than 950,000 practitioners who received a collective $90 billion...

Steptoe & Johnson PLLC: Under Stark, ‘Value’ Doesn’t Mean ‘Expensive’

The federal Stark law prohibits physician referrals of “designated health services” payable by Medicare to entities with which the physician or an immediate family member has a financial relationship, unless the arrangement meets an exception. Enforcement initiatives aim at extending the...

Williams Mullen: Affirming the Need to Fix the Medicare Appeals Backlog: The AFIRM Act of 2015

By: Kelsey S. Farbotko If you are one of the many health care providers wanting to appeal a Medicare contractor’s reimbursement decision, you may need to be prepared for a long wait. Over the last few years, the backlog of appeals to the administrative hearing level has grown into an untenable...

Cadwalader: Federal Court Upholds Provider Mandate to Report and Return Medicare and Medicaid Overpayments in 60 Days

Introduction | The Patient Protection and Affordable Care Act (“PPACA”), signed into law on March 23, 2010, included a provision (the “Report and Refund Mandate”), broadly requiring health care providers, suppliers, Part D plans and managed care organizations that were overpaid...

Williams Mullen: The Definition of Identify: The 60-Day Rule

By Ruth Levy & Patrick C. Devine, Jr. | The Patient Protection and Affordable Care Act (“PPACA”) established that any person who receives an overpayment from the Medicare or Medicaid programs and who does not report and return the overpayment within 60 days after it is identified will...

Settlement Not Binding When CMS Never Approved Medicare Set-Aside: Cal. Comp. Cases October Advanced Postings (9/24/2015)

Here’s the latest batch of advanced postings for the October 2015 issue of Cal. Comp. Cases. Lexis.com and Lexis Advance subscribers can link to the case to read the complete headnotes and summaries. © Copyright 2015 LexisNexis. All rights reserved. Calvin Collins, Petitioner v...

Pennsylvania: Claimant Retires and Moves to Nevada, but Court Says No Evidence She Withdrew From Workforce

A Pennsylvania appellate court held that it was error to suspend a claimant’s benefits solely because she received a disability pension and had moved to Nevada for its warmer climate; there was no evidence that she had permanently removed herself from the workforce. The claimant indicated her body...

An Alarming Mortality and Morbidity Trend Among Middle-Aged White Non-Hispanic Americans Suggests Implications for Ability to Work

Despite strides in medical care, mortality/morbidity is rising among this important demographic due to drugs, alcohol, suicide, liver disease and cirrhosis According to a study recently released by two Princeton University economists, the broadly observed long-term decline in mortality rates among...

CMS Issues Anticipated Medicare Overpayments Final Rule; Relaxes Initial Proposals

by Frederick Robinson , Thomas Dowdell , Carol Poindexter , Mark Faccenda , Selina Coleman and Blake Walsh* On February 11, 2016, DHHS’s Centers for Medicare & Medicaid Services (CMS), issued a final rule clarifying the requirement of § 1128J(d) of the Social Security Act (created by...

Here’s Why You Shouldn’t Miss the WCRI 32nd Annual Conference

Anyone familiar with the Workers Compensation Research Institute’s 32-year history of providing the data and analysis that industry mavericks rely upon to understand, manage and effect real change have come to expect WCRI conferences to provide the discussion and debate of cutting edge issues and...

California Workers’ Comp Case Roundup (4/29/2016)

CALIFORNIA COMPENSATION CASES Vol. 81 No. 4 April 2016 A Report of En Banc and Significant Panel Decisions of the WCAB and Selected Court Opinions of Related Interest, With a Digest of WCAB Decisions Denied Judicial Review CONTENTS OF THIS ISSUE © Copyright 2016 LexisNexis. All rights...

California Workers' Comp Case Roundup (2/5/2017)

CALIFORNIA COMPENSATION CASES Vol. 82 No. 1 Jan 2017 A Report of En Banc and Significant Panel Decisions of the WCAB and Selected Court Opinions of Related Interest, With a Digest of WCAB Decisions Denied Judicial Review CONTENTS OF THIS ISSUE © Copyright 2017 LexisNexis. All rights...

Trends to Watch in Workers’ Compensation Law

At the National Workers’ Compensation & Disability Conference last November, Brad Bleakney, a partner with Bleakney & Troiani, and Lora Northen, a Shareholder with Capehart Scatchard, led a seminar on recent trends in workers’ compensation. The following is a Q&A with Brad and...

California: Does a Home Care Assessment Constitute “Treatment” Subject to Utilization Review?

Fine Lines and a Glimpse at the Future In Rodriguez v. Simi Valley Unified School District, 2016 Cal. Wrk. Comp. P.D. LEXIS 671 , applicant, a custodian, sustained injury at her employer. The injury was sufficiently serious that her treating physician deemed it necessary to ask that an independent...