News & Analysis as of

Compliance Medicaid

Compliance programs typically refer to formalized institutional procedures within corporations and organizations to detect, prevent and respond to indvidual and widespread instances of regulatory violations. ... more +
Compliance programs typically refer to formalized institutional procedures within corporations and organizations to detect, prevent and respond to indvidual and widespread instances of regulatory violations.  In response to many corporate scandals evidencing rampant unethical business practices, many nations, including the United States, began passing strict regulatory frameworks aimed at curbing these abuses. Notable pieces of legislation in this area include the U.S. Foreign Corrupt Practices Act (FCPA), Sarbanes-Oxley (SOX), and the U.K. Bribery Act, to name a few. The foregoing statutes and the severe penalties often associated with them form the basis of many modern institutional compliance programs. less -
Hanzo

Compliance Under Pressure: Audit Readiness for Healthcare Providers

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In today’s healthcare environment, compliance is a defining element of patient care quality, operational integrity, and public trust. Oversight from agencies such as the Office for Civil Rights (OCR), the Centers for Medicare...more

Holland & Hart LLP

Correcting Stark Violations: 90-Day Grace Period

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Physicians and entities to which physicians refer may violate the Ethics in Patient Referrals Act (“Stark”) by mistakenly overpaying or underpaying amounts due under a compensation arrangement. For example, a hospital may...more

Oberheiden P.C.

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

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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

Paul Hastings LLP

CMS Proposes Major ASP Reporting Overhaul — Implications for Fair Market Value and Bona Fide Service Fees

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The Centers for Medicare & Medicaid Services (CMS) recently published its Proposed 2026 Physician Fee Schedule Rule (Proposed Rule), with extensive implications for drug pricing, Average Sales Price (ASP) calculations, and...more

McNees Wallace & Nurick LLC

Navigating Pa.’s unique IBHS licensing requirement for ABA therapy providers

Per Autism Speaks’ “Autism by the Numbers: 2025 Annual Report” (see autismspeaks.org/ABN, last visited July 20, 2025), currently one in 35 children in the United States has autism....more

McDermott Will & Schulte

Key updates on the US health benefits and reimbursement landscape

The world of health benefits is constantly evolving. Recent policy shifts and legislative developments are expected to impact the economic landscape and have significant implications for employer plan sponsors, insurers,...more

King & Spalding

The One Big Beautiful Bill Act Explained: A Detailed Review of Key Changes for the Healthcare Industry

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To offset the cost of other provisions in the bill, the One Big Beautiful Bill Act (OBBBA) includes significant reforms to Medicaid, Medicare, and Affordable Care Act (ACA) premium tax credits that are expected to result in...more

Dentons

Ep. 70 – Use Caution Before Charging Patients Extra Fees

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As healthcare providers face mounting administrative burdens and tighter reimbursement rates, some are exploring the idea of charging patients for “extra” services, such as administrative tasks or added “perks.” But before...more

Polsinelli

HCBS Update: Indiana Implements Home-Grown 70/30 Direct Caregiver Compensation Requirement

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Executive Summary: On July 10, 2025, Indiana Medicaid issued guidance to providers of attendant care and structured family caregiver services requiring providers to pass through a specific percentage of their Medicaid...more

Foley & Lardner LLP

Colorado Medicaid: RAC Program Overhauled with Enhanced Transparency, Greater Provider Protections, and Increased Oversight

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In June 2025, Colorado passed a new law that makes significant changes to the state’s Medicaid Recovery Audit Contractor (RAC) program. Colorado has one of the most aggressive RAC programs in the country that has been rife...more

Harris Beach Murtha PLLC

OMIG Announces 12-Month Review Period for its Compliance Program Reviews

The New York State Office of the Medicaid Inspector General (“OMIG”) issued a Listserv Notice on June 26, 2025 advising that its Compliance Program Reviews (“CPRs”) beginning after July 1, 2025, will use a 12-month Review...more

Dentons

Ep. 68 – Before You Audit—Why Pre-Audit Planning Matters

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If you’re preparing to launch an audit within your healthcare organization, pause for a moment and consider this: how well you plan before the audit begins can significantly affect the outcome—and your risk exposure. This...more

Health Care Compliance Association (HCCA)

HHS OIG’s Nursing Facility: Industry Segment-Specific Compliance Program Guidance

In November 2024, the Office of Inspector General at Health and Human Services released its Nursing Facility: Industry Segment-Specific Compliance Program Guidance. The document is part of an effort to modernize how HHS OIG...more

ArentFox Schiff

Telehealth Staffing and Administrative Services Gain Favorable Advisory Opinion From OIG

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On June 6, the US Department of Health and Human Services’ Office of Inspector General (OIG) issued Advisory Opinion No. 25-03, providing important guidance for telehealth organizations and management services organizations...more

DLA Piper

OIG Issues Favorable Advisory Opinion on Telehealth Marketplace MSO-PC Arrangement

DLA Piper on

The Department of Health and Human Services, Office of Inspector General (OIG) recently issued a favorable advisory opinion under the federal Anti-Kickback Statute (AKS), wading into the world of not only telehealth but also...more

Bass, Berry & Sims PLC

Healthcare Regulatory & Compliance Summit 2025 Recap

Health Policy Fireside Chat: What to Expect from the New Administration - Bill Mathias, Member at Bass, Berry & Sims, engaged in a fireside chat with Colin Roskey, Principal at FHP Strategies, former Deputy Assistant...more

Husch Blackwell LLP

Navigating Compliance Risks in Laboratory Operations—Key Lessons from a Recent FCA Case

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A recent False Claims Act (FCA) litigation—Jensen ex rel. United States of America v. Genesis Laboratory—highlights critical compliance risks for laboratories. This case reinforces the need for laboratories to ensure...more

Health Care Compliance Association (HCCA)

Healthcare Industry Segment-Specific Compliance Program Guidances (ICPGs)

In addition to releasing its General Compliance Program Guidance, the OIG at HHS announced plans to publish a series of Industry Segment-Specific Compliance Program Guidances (ICPG). The first of these, addressing nursing...more

Polsinelli

HCPF Makes Clarifications to Mandatory Facility-Based Professionals’ Reporting Requirements Under Colorado Hospital Discounted...

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What is Colorado Hospital Discounted Care? Colorado’s Hospital Discounted Care law, effective September 1, 2022, brought a detailed and comprehensive yet highly confounding overhaul to the way hospitals, freestanding...more

Cozen O'Connor

Texas AG Settles for $40 Million Over Medicaid Fraud Allegations

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Texas AG Ken Paxon announced a settlement with Molina Healthcare of Texas, Inc. and Molina Healthcare, Inc. (collectively, “Molina”), to resolve allegations of Medicaid fraud. The AG’s office claims Molina violated the Texas...more

McDermott Will & Schulte

OIG Nursing Facility Compliance Program Guidance: Renewed Focus on Fraud and Abuse

The US Department of Health and Human Services Office of Inspector General’s (OIG’s) release of Nursing Facility Industry Segment-Specific Compliance Program Guidance (ICPG) for the first time since 2008 reemphasizes the...more

Whiteford

Client Alert: CMS Again Delays Updates to its Guidance to Surveyors for Long Term Care Facilities Under Appendix PP of the State...

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On March 10, 2025, the Centers for Medicare & Medicaid Services (“CMS”) announced a further delay in the implementation of proposed updates to its Guidance to Surveyors for Long-Term Care Facilities under Appendix PP of the...more

Cozen O'Connor

Walgreens Settles With 50 AGs and U.S. DOJ Over Allegedly Billing for Uncollected Prescriptions

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A bipartisan coalition of 50 AGs settled with Walgreens Boots Alliance, Inc. and Walgreen Co. (collectively, “Walgreens”) to resolve allegations that they billed federal and state government health care programs for...more

Rivkin Radler LLP

Provider and Beneficiaries Conspired to Defraud Louisiana’s Medicaid Program

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Healthcare fraud is prevalent within state Medicaid programs due to the massive amounts of money flowing through the system. In Louisiana, the Estate of Yolanda Burnom and her former company, Community Healthcare Solutions,...more

Foley & Lardner LLP

Key Takeaways: 7th Annual “Let’s Talk Compliance” Conference

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Editor’s Note: PYA and Foley & Lardner hosted the 7th Annual “Let’s Talk Compliance” two-day virtual conference on January 23 and 24, 2025. Panelists included Foley attorneys and PYA subject matter experts. The event was...more

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