Julia Tamulis on Medicare

More Losses than Gains? OIG Declines to Approve Certain Medicare Advantage Gainsharing Arrangements in Advisory Opinion 24-08

On September 13, the U.S. Department of Health and Human Services Office of Inspector General (OIG) published Advisory Opinion 24-08, in which it declined to approve a proposal by a Medicare Advantage organization (MAO)...more

9/19/2024 / Advisory Opinions , Anti-Kickback Statute , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Employer Group Health Plans , Health Insurance , Healthcare , Medicare , Medicare Advantage Organizations (MAOs) , OIG , Shared Savings Program

The ABCs of Medicare and Medicaid Claims Audits: Responding to Audits and Potential Consequences from Negative Audits

As addressed in the first installment of this three-part series, healthcare providers face potential audits from an increasing number of Medicare and Medicaid contractors. Failing to respond properly can lead to significant...more

2/22/2023 / Appeals , Audits , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Health Care Providers , Medicaid , Medicare , Medicare Advantage Organizations (MAOs)

CMS Finalizes Long-Awaited RADV Program Rule

On February 1, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Program Final Rule (Final Rule), which will take effect on April 3, 2023. The...more

2/7/2023 / Centers for Medicare & Medicaid Services (CMS) , Final Rules , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , Overpayment

CMS Proposed Rule Addresses Multiple Aspects of Medicare Advantage Program for 2024, Including an Overpayment Rule Update

On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024....more

12/21/2022 / Centers for Medicare & Medicaid Services (CMS) , Comment Period , Department of Health and Human Services (HHS) , Equity , Health Care Providers , Marketing , Medicare , Medicare Advantage , Medicare Part A , Medicare Part B , Medicare Part C , Medicare Part D , Notice Requirements , Overpayment , Proposed Rules , Star Ratings , Termination Clauses , Translations , Utilization Review

CMS Advisory Opinion Provides Flexibility Under Stark for Group Practice Structures Involving Wholly-Owned Physician Practice...

The Centers for Medicare & Medicaid Services (CMS) recently issued Advisory Opinion No. CMS-AO-2021-01, clarifying that physician groups that furnish designated health services (e.g., laboratory, imaging) through wholly-owned...more

7/13/2021 / Advisory Opinions , Centers for Medicare & Medicaid Services (CMS) , Contractors , Employees , Health Care Providers , Healthcare Facilities , Medicare , Medicare Beneficiaries , Physician Ownership , Stark Law

Healthcare Fraud & Abuse Review 2020

Ensuring compliance with the False Claims Act has never been more important for healthcare providers. By March 2020, we saw healthcare professionals standing at the forefront of one of the greatest health crises in a...more

Judicial Opinions Support Delay of Recoupment from Audit Appeals Until After ALJ Hearings in Certain Circumstances

Recent opinions by the Fifth Circuit, the Northern and Southern Districts of Texas, and the District of South Carolina offer hope to providers seeking relief from substantial monetary recoupments during the Medicare appeals...more

9/28/2018 / Administrative Appeals , Administrative Law Judge (ALJ) , Administrative Remedies , Audits , Centers for Medicare & Medicaid Services (CMS) , Complaint Procedures , Health Care Providers , Injunctive Relief , Irreparable Harm , Medicare , Medicare Claims Appeals Process , Motion for Reconsideration , OMHA , Overpayment , Physician Medicare Reimbursements , Recoupment , Redeterminations , TRO

CMS Offers Expanded Settlement Options to Reduce Appeals Backlog

In January 2018, Centers for Medicare & Medicaid Services (CMS) announced additional information regarding a new Low Volume Appeals (LVA) settlement option and an expanded Settlement Conference Facilitation (SCF) as part of...more

4/13/2018 / Administrative Law Judge (ALJ) , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Low Volume Appeals Settlement Options (LVA) , MACs , Medicare , Medicare Appeals Council , Medicare Claims Appeals Process , Medicare Part A , Medicare Part B , OMHA

Julia Tamulis

Bass, Berry & Sims PLC

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