Brian Dunphy on Centers for Medicare & Medicaid Services (CMS)

EnforceMintz — Artificial Intelligence and False Claims Act Enforcement

Like most industries, the health care sector is grappling with the uses of artificial intelligence (AI) and what AI means for the future. At the same time, many health care companies already have integrated algorithms and AI...more

2/13/2024 / Algorithms , Artificial Intelligence , Centers for Medicare & Medicaid Services (CMS) , Department of Justice (DOJ) , Enforcement , False Claims Act (FCA) , Health Care Providers , Health Technology , Healthcare , Medicare Advantage , Natural Language Processing , Popular , Qui Tam , Whistleblowers

EnforceMintz — Government Scrutiny of Medicare Advantage Organizations Expected to Continue in 2024

Medicare Advantage (also known as Medicare Part C) remains a top enforcement priority as evidenced by False Claims Act (FCA) investigations and litigation involving nearly all large Medicare Advantage Organizations (MAOs). As...more

2/12/2024 / Beneficiaries , Centers for Medicare & Medicaid Services (CMS) , Cybersecurity , Data Mining , Department of Health and Human Services (HHS) , Department of Justice (DOJ) , Enforcement , False Claims Act (FCA) , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , OIG

EnforceMintz — Medicare Advantage Remains a Top Enforcement Priority

Medicare Advantage (Medicare Part C) remained a top enforcement priority in 2022, and Medicare Advantage Organizations (MAOs) are the subject of intense scrutiny by the Department of Justice (DOJ); the Office of Inspector...more

2/13/2023 / Anti-Kickback Statute , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Department of Justice (DOJ) , Enforcement , False Claims Act (FCA) , Medicare Advantage , Medicare Part C , OIG , Proposed Rules

Five Takeaways from DOJ’s Latest National Enforcement Action, Including Continued Focus on Opioids and Telemedicine

The U.S. Department of Justice (DOJ) recently announced its latest national enforcement action related to health care fraud (National Enforcement Action) in which DOJ filed criminal charges against 142 defendants. The...more

9/28/2021 / Centers for Medicare & Medicaid Services (CMS) , Coronavirus/COVID-19 , Department of Justice (DOJ) , Enforcement Actions , Fraud , Healthcare Fraud , Medicare Fraud , Opioid , Substance Abuse , Telemedicine

DOJ Files False Claims Act Lawsuit Against Anthem for “One-Sided” Chart Review Practices

The Department of Justice (DOJ) recently filed suit against Anthem, Inc. (Anthem) alleging that the Medicare Advantage Organization (MAO) violated the False Claims Act (FCA) when it knowingly failed to delete inaccurate...more

4/8/2020 / Centers for Medicare & Medicaid Services (CMS) , Department of Justice (DOJ) , False Claims Act (FCA) , Health Insurance , ICD Codes , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , Medicare Part C , Qui Tam

CMS Finalizes Changes Expanding the Scope of the Open Payments Program

On November 15, 2019, the Centers for Medicare & Medicaid Services ("CMS") finalized changes to the Open Payments Program as part of the CY 2020 Physician Fee Schedule Final Rule. The Open Payments reporting requirements,...more

11/18/2019 / Centers for Medicare & Medicaid Services (CMS) , Continuing Medical Education , Final Rules , Health Care Providers , Medicaid , Medicare , Open Payments , Physician Fee Schedule , Physicians , Reporting Requirements , Sunshine Act , Unique Device Identifiers

Open Payments Program Expansion

On July 30, 2019, the Centers for Medicare & Medicaid Services ("CMS") announced more proposed changes to the Open Payments Program. The Open Payments reporting requirements, otherwise known as the Sunshine Act, require...more

8/13/2019 / Centers for Medicare & Medicaid Services (CMS) , Covered Recipients , Health Care Providers , Medical Supplies , Open Payments , Opioid , Physician Fee Schedule , Physicians , Proposed Rules , Public Comment

President’s Budget Blueprint Increases Funds For Health Care Fraud Enforcement

The President has released a “budget blueprint” for fiscal year 2018. Although there are many aspects of the budget blueprint to digest, several budget items signal that government health care fraud enforcement remains a...more

3/17/2017 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Federal Budget , Fraud and Abuse , Healthcare Fraud , Legislative Agendas , Qui Tam , Trump Administration

The Medicare Overpayment Rule: Implications for Compliance and Health Care Enforcement

As has been widely discussed, the Centers for Medicare & Medicaid Services (‘‘CMS’’) Feb. 12 published the long-awaited final rule governing the return of Medicare Part A and Part B overpayments within 60 days (the...more

3/2/2016 / Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , False Claims Act (FCA) , Healthcare Fraud , Look-Back Measurement Period , Medicare , Medicare Part A , Medicare Part B , Overpayment Recovery Time Limits

The Final 60-Day Rule: the Good, the Bad, and the Ugly

As we announced on February 11, 2016, the Centers for Medicare & Medicaid Services (CMS) has finally published the long-awaited Final Rule governing the return of Medicare Part A and Part B overpayments within 60 days (the...more

2/15/2016 / 60-Day Rule , Centers for Medicare & Medicaid Services (CMS) , Civil Monetary Penalty , False Claims Act (FCA) , Final Rules , Medicare Part A , Medicare Part B , Overpayment

Skeletons in the Closet? Beware of Potential Enforcement Actions

With Halloween looming, a discussion of skeletons that may be lurking in a health care provider’s closet is timely. Many of our previous posts, as well as the monthly Qui Tam Updates published by our Health Care Enforcement...more

Medicare Part D Data Release Continues Transparency Trend

The Centers for Medicare & Medicaid Services (CMS) recently added to the trend toward greater health care data transparency by releasing data about the prescription drugs that physicians and other health care providers...more

5/8/2015 / Centers for Medicare & Medicaid Services (CMS) , Healthcare , Information Sharing , Medicare , Medicare Part D , Physician Medicare Reimbursements , Sunshine Act , Transparency

CMS Delays 60-Day Rule, But Overpayment Case Law Emerging

The Centers for Medicare & Medicaid Services (CMS) recently announced a one-year delay in finalizing the long-awaited and closely watched rule addressing the 60-day deadline to return Medicare and Medicaid overpayments (the...more

2/24/2015 / Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , Civil Monetary Penalty , Department of Homeland Security (DHS) , Department of Justice (DOJ) , Financial Conduct Authority (FCA) , Medicaid , Medicare , Overpayment , Physician Medicare Reimbursements , Qui Tam , Relators , Social Security Act

CME Payments Largely Remain Excluded From Sunshine Act Reporting

The Centers for Medicare & Medicaid Services (“CMS”) has finalized changes to a number of reporting requirements under the regulations implementing the Physician Payments Sunshine Act (“Final Rule”). When CMS proposed...more

11/5/2014 / Centers for Medicare & Medicaid Services (CMS) , Final Rules , Medical Devices , Pharmaceutical Industry , Physicians , Reporting Requirements , Sunshine Act

CMS Temporarily Closes the Open Payments System

Open Payments is the website through which pharmaceutical and medical device manufacturers (“Manufacturers”) report payments and transfers of value to physicians and teaching hospitals, as required by the Sunshine Act. ...more

8/13/2014 / Centers for Medicare & Medicaid Services (CMS) , Healthcare , Healthcare Reform , Open Payments , Sunshine Act

Physician Groups Seek Sunshine Act Changes

Seventy-four state and federal physician organizations, including the American Medical Association, recently asked the Centers for Medicare & Medicaid Services (“CMS”) to exclude textbooks and peer-reviewed medical journal...more

11/1/2013 / Centers for Medicare & Medicaid Services (CMS) , Medical Devices , Pharmaceutical Industry , Reporting Requirements , Sunshine Act

PRIME Act: New Legislation to Curb Health Care Fraud

The United States Senate and House of Representatives recently introduced bipartisan legislation designed to reduce fraud, waste, and abuse in the Medicare and Medicaid programs. The legislation, entitled “Preventing and...more

6/17/2013 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Fraud , Information Sharing , Medicaid , Medicare , Overpayment , Proposed Legislation , Recovery Audit Contractors (RACs) , Waste

Updated Self-Disclosure Protocol Clarifies Disclosure Process and Obligations

Individuals and entities subject to the Civil Monetary Penalty Law (CMP) have received clarification regarding the process for disclosing and resolving potentially unlawful conduct involving the federal health care programs...more

4/23/2013 / Centers for Medicare & Medicaid Services (CMS) , Damages , Disclosure Requirements , OIG , Overpayment , Self-Disclosure Requirements

CMS Publishes Final Sunshine Act Rule Creating New Regulatory Landscape for Physician-Manufacturer Interactions

Originally published in the Health Care Fraud Report, 17 HFRA 219, on 03/06/2013. The final rule (the ‘‘Final Rule’’) implementing the Physician Payments Sunshine Act (‘‘Sunshine Act’’), published in the Federal...more

3/7/2013 / Centers for Medicare & Medicaid Services (CMS) , Joint Purchasing Programs , Pharmaceutical Industry , Physicians , Sunshine Act

CMS Publishes Final Sunshine Act Rule; Data Collection to Begin on August 1, 2013

The long-awaited final rule (the Final Rule) implementing the Physician Payments Sunshine Act (Sunshine Act) has arrived at the Federal Register. It amends key definitions and adds new terms; retains broad reporting...more

2/5/2013 / Centers for Medicare & Medicaid Services (CMS) , Compliance , Continuing Medical Education , Data Collection , Enforcement , GPOs , Medicaid , Medical Devices , Medical Supplies , Payment Records , Pharmaceutical Industry , Physicians , Reporting Requirements , Sunshine Act

Let the Collection and Reporting Begin: CMS Publishes Final Sunshine Act Regulations