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Compliance Medicare Advantage

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 -
White & Case LLP

DOJ and HHS Relaunch False Claims Act Working Group, Sharpen Healthcare Enforcement Priorities

White & Case LLP on

On July 2, 2025, the U.S. Department of Justice (DOJ) and the Department of Health and Human Services (HHS) jointly announced the reestablishment of the DOJ-HHS False Claims Act (FCA) Working Group. While the two agencies...more

ArentFox Schiff

FCA Enforcement & Compliance Digest — Summer 2025 False Claims Act Newsletter

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Welcome to the Summer 2025 issue of “FCA Enforcement & Compliance Digest,” our quarterly newsletter in which we compile essential updates on False Claims Act (FCA) enforcement trends, litigation, agency guidance, and...more

Health Care Compliance Association (HCCA)

[Event] Healthcare Basic Compliance Academy - July 21st - 24th, Nashville, TN

Grounded in the OIG’s General Compliance Program Guidance and DOJ’s Evaluation of Corporate Compliance Programs, our immersive, three-and-a-half-day, classroom-style Healthcare Basic Compliance Academy equips compliance...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

Bass, Berry & Sims PLC

HHS-OIG Year in Review 2024

In 2024, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) provided useful insights to the healthcare industry regarding how it approaches various fraud and abuse issues in an...more

Proskauer - Health Care Law Brief

CMS Publishes Final Rule, Effective January 1, 2025, Addressing the Requirements for Reporting and Returning Overpayments

The standard for an “identified overpayment” under Medicare Parts A–D now aligns with section 1128J(d)(4)(A) of the Social Security Act, which incorporates by reference the Federal False Claim Act’s (the “FCA”) “knowledge”...more

ArentFox Schiff

Investigations Newsletter: Massachusetts District Court Judge Applies Heightened Causation Standard in FCA Case

ArentFox Schiff on

Massachusetts District Court Judge Applies Heightened Causation Standard in FCA Case - On January 6, a District Court of Massachusetts judge granted summary judgment for defendants on allegations of violating the...more

Mintz - Health Care Viewpoints

EnforceMintz — FCA Enforcement in Value-Based Care Arrangements Heated Up in 2024 and Likely to Remain a Priority in 2025

Value-based care (VBC) is a health care delivery model that has grown increasingly common in recent years. Perhaps unsurprisingly, this growth seems to have attracted the attention of government enforcement agencies...more

Mintz - Health Care Viewpoints

EnforceMintz — Medicare Advantage and Part D Programs to Remain in the Enforcement Spotlight in 2025

As government scrutiny and enforcement targeting the Medicare Advantage (Medicare Part C) program continued in 2024, the industry’s response to agency actions escalated. Last year also resulted in the first sizable Part D...more

Mintz - Health Care Viewpoints

EnforceMintz — Scienter, Causation, and Constitutional Questions: 2024’s Three Key FCA Litigation Issues

In 2024, federal courts issued a number of important decisions in False Claims Act (FCA) cases that are particularly noteworthy for the health care and life sciences industries. We focus here on decisions that further develop...more

Polsinelli

The OIG’s Concerns with Potentially Fraudulent Medicare Advantage Marketing

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The HHS Office of Inspector General (“OIG”) released a Special Fraud Alert to inform health care professionals (“providers”) and Medicare Advantage Organizations (“MAOs”) about the OIG’s view of potentially abusive marketing...more

Proskauer - Health Care Law Brief

OIG Releases Special Fraud Alert About Suspect Payments in Marketing Arrangements Related to Medicare Advantage and Providers

On December 11, 2024, the Office of Inspector General for the U.S. Department of Health and Human Services (“OIG”) issued a special fraud alert warning about certain marketing schemes that involve questionable payments and...more

Goodwin

Health Headlines - December 2024

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Welcome to the first issue of Health Headlines, a newsletter created by lawyers in our Healthcare practice. In this issue, we cover Medicare Part C oversight, new cybersecurity legislation, healthcare lawsuits and deals, and...more

Ankura

Is there room for AI in the ICU? Guiding Principles and Compliance Considerations

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Artificial Intelligence (AI) offers unprecedented opportunities to enhance patient care, streamline clinical documentation, and support medical decision-making processes. More and more healthcare professionals find themselves...more

Health Care Compliance Association (HCCA)

Early returns on MA plans’ two-midnight rule interpretations: A compliance nightmare

The Centers for Medicare and Medicaid Services (CMS) issued regulations applicable to Medicare Advantage (MA) plans—also commonly referred to as managed Medicare or Part C Medicare—in April 2023 (CMS 4201–F) that address,...more

Furia Rubel Communications, Inc.

Navigating the Regulatory Complexities of an Evolving Health Care System with Kathleen Fisher Enyeart, Counsel at Lathrop GPM

In this episode of On Record PR, Gina Rubel goes on record with Kathleen Fisher Enyeart, Counsel at Lathrop GPM, to discuss the challenges of complying with health care regulations in a complex and rapidly changing industry....more

Health Care Compliance Association (HCCA)

CMS issues additional guidance to clarify new MA regulations

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published an expansive final rule amending Medicare Advantage (MA) regulations related to, among other things, coverage criteria and prior authorization....more

Ankura

OIG Testimony Puts a Spotlight on Clinical Documentation and Payer Risk

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In recent testimony before the United States House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, Christi A. Grimm, Inspector General of the Department of Health and Human Services (HHS)...more

Venable LLP

Navigating the Future: Medicare Advantage Plan Rules on the Use of Artificial Intelligence

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The use of technology in healthcare services and payment for healthcare is evolving at an unprecedented pace, reshaping how medical services are delivered, managed, and paid for. The use of artificial intelligence systems...more

Alston & Bird

DOJ Reports Record Number of New False Claims Act Matters, Recoveries for 2023

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Our False Claims Act (FCA) Team examines the Department of Justice’s increased focus on enforcement of the FCA, especially in health care matters. The DOJ initiated over 1,000 FCA matters in one year for the first time....more

Holland & Knight LLP

Key Value-Based Care Developments to Watch in 2024

Holland & Knight LLP on

The goal of value-based care (VBC) is to promote better care for individual patients and improved health outcomes for communities at reduced costs. This is an important and admirable purpose as many VBC stakeholders attempt...more

Foley & Lardner LLP

“Let’s Talk Compliance”: OIG’s General Compliance Program Guidance: How to Refresh Compliance Programs

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Editor’s Note: PYA and Foley & Lardner hosted the 6th Annual “Let’s Talk Compliance” two-day Virtual Conference on January 18 and 19, 2024. Panelists included Foley & Lardner attorneys and PYA experts. The event was hosted by...more

Bricker Graydon LLP

A Long-Awaited Change: OIG Updates its Compliance Program Guidances

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From 1998-2008, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published compliance program guidelines for various industries in the Federal Register....more

WilmerHale

Criminal Indictment for Medicare Advantage Fraud

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The U.S. Department of Justice (DOJ) recently announced a rare criminal indictment involving the Medicare Advantage program—a contrast from DOJ’s more typical use of its civil enforcement authority to pursue similar issues...more

Harris Beach Murtha PLLC

HHS Office of Inspector General August 2023 Enforcement Activity

The following is a summary of selected federal Department of Health and Human Services’ Office of Inspector General (OIG) reports of fraud and abuse enforcement activity across the country. The enforcement actions reported...more

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