Nick Oberheiden on Centers for Medicare & Medicaid Services (CMS)

Pharmacy Claim Reversals: Mitigating Risk Before, During, and After an Investigation

Pharmacy claim reversals can be costly. Not only can they have an immediate impact on pharmacies’ cash flow; but, in many cases, they can lead to additional consequences as well. Pharmacies accused of improperly billing...more

8/26/2025 / Audits , Centers for Medicare & Medicaid Services (CMS) , Compliance , False Claims Act (FCA) , Health Care Providers , Healthcare , Medicaid , Medicare , Pharmacies , Risk Management

What Does it Take to Win Medicare Appeals in 2024?

Lots of health care service providers find themselves in the position of needing to file a Medicare appeal. Despite the systematic nature of modern Medicare billing, wrongful denials remain common, and errors during Medicare...more

3/26/2024 / Auditors , Billing , Centers for Medicare & Medicaid Services (CMS) , Denial of Insurance Coverage , Health Care Providers , Medicare , Medicare Appeals , OMHA , Physician Medicare Reimbursements , Redeterminations , Reimbursements

DOJ Announces Criminal Charges in Alleged $1.2 Billion Health Care Fraud Scheme

Yesterday, the U.S. Department of Justice (DOJ) announced that it has filed charges against 36 defendants in relation to an alleged health care fraud scheme that resulted in approximately $1.2 billion in fraudulent payments....more

7/21/2022 / Centers for Medicare & Medicaid Services (CMS) , Criminal Prosecution , Department of Justice (DOJ) , Enforcement Actions , FBI , Health Care Providers , Healthcare Fraud , Kickbacks , Medicare , Medicare Beneficiaries , Physician Medicare Reimbursements , Physicians , Telehealth , Telemarketing , Telemedicine

5 Key Healthcare Audit Defense Strategies

Nearly all healthcare providers will face an audit (if not multiple audits) during their careers. Federal agencies such as the U.S. Department of Health and Human Services (HHS) routinely audit healthcare providers for...more

7/20/2022 / Auditors , Audits , Centers for Medicare & Medicaid Services (CMS) , Defense Strategies , Department of Health and Human Services (HHS) , Health Care Providers , Healthcare Fraud

Medicare TPE Audits: 7 Common Questions Answered

The Centers for Medicare and Medicaid Services (CMS) and its audit contractors have recently increased their use of Targeted Probe and Educate (TPE) audits to target providers suspected of improperly billing Medicare. While...more

6/21/2022 / Billing , Centers for Medicare & Medicaid Services (CMS) , Criminal Investigations , Health Care Providers , Healthcare Fraud , Medical Billing Codes , Medical Records , Medicare , Medicare Administrative Contractors (MAC) , Medicare Appeals , Medicare Fraud , Penalties , Physicians , Targeted Probe and Education (TPE) audit

6 Frequently Asked Questions with Lab Defense Attorney Nick Oberheiden

Clinical laboratories have come under increased scrutiny in the past few years, especially those that deal with COVID-19 testing or drug testing. These federal investigations can be surprising and confusing for lab...more

4/5/2022 / Anti-Kickback Statute , Centers for Medicare & Medicaid Services (CMS) , Civil Liability , CLIA , Clinical Laboratories , Criminal Liability , Defense Strategies , Department of Justice (DOJ) , False Claims Act (FCA) , FBI , Food and Drug Administration (FDA) , Health Care Providers , Healthcare Fraud , Investigations , OIG , Penalties , Physicians , Stark Law

What You Need to Know About Continuous Glucose Monitoring Compliance

For diabetic patients and the doctors who treat them, blood sugar levels are crucially important. However, the traditional method of testing one’s blood sugar with a pin-prick is undesirable for many patients, which leads to...more

11/23/2021 / Centers for Medicare & Medicaid Services (CMS) , Defense Strategies , Department of Health and Human Services (HHS) , Health Care Providers , Investigations , Medical Devices , Medical Necessity , Medicare , OIG , Policies and Procedures

Federal Government Targets Providers Administering Amniotic Injections

The federal government has recently made clear its intention to go after healthcare providers who provide amniotic injections to certain Medicare and Medicaid recipients. Over recent years, the federal government has...more

10/26/2021 / Anti-Kickback Statute , Billing , Centers for Medicare & Medicaid Services (CMS) , Civil Investigation Demand , Civil Liability , Criminal Liability , Defense Strategies , Eliminating Kickbacks in Recovery Act of 2018 (EKRA) , False Claims Act (FCA) , Government Investigations , Health Care Providers , Healthcare Fraud , Medicaid , Medicare , Physicians , Stark Law

Federal Authorities Place Cardiovascular Stress Testing Under the Microscope

Cardiovascular stress testing to diagnose patients with coronary artery disease (CAD) and other related types of conditions can be a highly-effective tool in many cases. In fact, many cardiologists routinely recommend stress...more

8/24/2021 / Audits , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Department of Justice (DOJ) , Documentation , False Billing , Health Care Providers , Investigations , Local Coverage Determinations (LCDs) , Medical Necessity , Medicare , Medicare Fraud , OIG , Policies and Procedures , Stress Tests

CMS and DOJ are Scrutinizing Medicare Billings for Amniotic Injections

The Centers for Medicare and Medicaid Services (CMS) and U.S. Department of Justice (DOJ) are scrutinizing health care providers’ Medicare billings for amniotic injections. These injections are only eligible for Medicare...more

8/17/2021 / Anti-Kickback Statute , Billing , Centers for Medicare & Medicaid Services (CMS) , Civil Investigation Demand , Department of Justice (DOJ) , Eliminating Kickbacks in Recovery Act of 2018 (EKRA) , False Claims Act (FCA) , Health Care Providers , Healthcare Fraud , Medicare , Medicare Fraud

Seven Points to be Aware of for Durable Medical Equipment Company Compliance

Durable medical equipment (DME) is particularly important for many Medicare beneficiaries. However, companies that manufacture and sell DME need to be careful because there are strict federal regulations outlining almost...more

UPIC and ZPIC Audits Defense: What Healthcare Providers Need to Know

Zone Program Integrity Contractors (ZPICs) and Unified Program Integrity Contractors (UPICs) are federal contractors who work under the direction of the Centers for Medicare and Medicaid Services (CMS) to uncover fraudulent...more

5/25/2021 / Audits , Centers for Medicare & Medicaid Services (CMS) , Defense Strategies , Department of Justice (DOJ) , Enforcement Actions , False Billing , Health Care Providers , Healthcare Fraud , Medicare , Overpayment , Provider Payments , Underpayment , Zone Program Integrity Contractors (ZPICs)

5 Defense Strategies for MAC/RAC Audits in 2025

Medicare pays billions of dollars in fraudulently billed claims each year. To recoup as many fraudulent reimbursements as possible, the Centers for Medicare and Medicaid Services (CMS) relies on various enforcement...more

4/6/2021 / Centers for Medicare & Medicaid Services (CMS) , Defense Strategies , Documentation , False Billing , Fraud and Abuse , Health Care Providers , Healthcare Fraud , MACs , Medicare , Physicians , Recovery Audit Contractors (RACs)

While COVID-19 Takes Center Stage, DOJ Continues to Target Providers for Opioid Epidemic

The COVID-19 pandemic has created many new enforcement priorities for the U.S. Department of Justice (DOJ). From selling ineffective personal protective equipment (PPE) to companies fraudulently seeking loan forgiveness under...more

Nick Oberheiden

Oberheiden P.C.

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