News & Analysis as of

Medicare Risk Management Healthcare

Polsinelli

Virtual Oversight, Real Impacts: “Incident-To” and Beyond in CMS’s CY 2026 PFS Proposed Rule

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Key Takeaways - CMS proposes to significantly expand the use of virtual direct supervision for incident-to services, removing prior limitations based on Professional Component (PC)/Technical Component (TC) indicators and...more

Sheppard Mullin Richter & Hampton LLP

Potential False Claims Act Liability for Providers of Gender-Affirming Care for Minors

On July 9, 2025, the U.S. Department of Justice (“DOJ”) announced it sent more than 20 subpoenas to physicians and clinics involved in providing gender-affirming care to minors, and that the subpoenas related to...more

White & Case LLP

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

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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

Polsinelli

CMS Proposes New Mandatory, Two-Sided Risk Model for Heart Failure and Low Back Pain

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Key Takeaways - CMS has proposed a mandatory two-sided risk model for specialists treating heart failure and low back pain in outpatient settings....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

King & Spalding

CMS Expands Auditing of Medicare Advantage Plans

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On May 21, 2025, CMS announced that it plans to increase its auditing efforts for Medicare Advantage (MA) plans. Effective immediately, CMS will audit all eligible MA contracts for each payment year in all newly initiated...more

Sheppard Mullin Richter & Hampton LLP

Takeaways from the America’s Physician Groups’ Spring Conference: Turbulent Times Call for Change and Innovation

“Kicking Off Accountable Care” served as the theme for this year’s America’s Physician Groups’ (“APG”) Spring Conference, a three-day event packed with compelling speakers and breakout sessions focused on the state of...more

McDermott Will & Emery

How PPM Health Plans Can Solve the MEWA Problem

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While a physician practice management (PPM) structure allows for compliance with corporate practice of medicine laws and ease of administration, it often creates inadvertent health plan issues that should be navigated...more

Harris Beach Murtha PLLC

A Balanced Approach: 10 Key Strategies to Minimize Bad Debt and Avoid Involuntary Terminations in Senior Living Communities

Senior living communities operate in a highly regulated and financially demanding environment, requiring operators to maintain fiscal stability while delivering exceptional care. As the senior population grows, providers face...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

Stotler Hayes Group, LLC

CMS Cracks Down on Responsible Party Liability in LTC Admission Agreements

A nursing facility that participates in the Medicaid or Medicare programs may not require a third party to guarantee payment for a resident’s admission or continued stay. However, facilities are allowed to require a resident...more

McCarter & English Blog: Government Contracts...

Antitrust Corporate Compliance Programs: Late 2024 Changes Mean Companies Should Revisit Their Programs Early in 2025

The US Department of Justice Antitrust Division (DOJ or Division) recently released a revised Evaluation of Corporate Compliance Programs in Criminal Antitrust Investigations (Guidance). The Guidance reflects how the Division...more

Ropes & Gray LLP

A Flurry of Healthcare Sector Cybersecurity Regulatory Developments in 2024

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2024 was a record year for cyberattacks in the healthcare sector. According to the Breach Portal maintained by the U.S. Department of Health and Human Services (“HHS”) Office of Civil Rights (“OCR”), to date this year, there...more

Arnall Golden Gregory LLP

OIG Updates Compliance Guidance for Nursing Facilities

In 1998, the Office of Inspector General (“OIG”) for the U.S. Department of Health and Human Services began issuing voluntary, compliance program guidance for various segments of the healthcare industry. Recently, the OIG has...more

Butler Snow LLP

Health Care Due Diligence: An Ounce of Prevention is Worth a Pound of Cure

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Due diligence properly performed in connection with the purchase and sale of a health care entity is simply different—vastly so—than due diligence performed in other contexts. Failure to recognize this reality can lead to...more

Health Care Compliance Association (HCCA)

Adding some spice to your compliance program

Every quarter, each acute care hospital that is paid under the Inpatient Prospective Payment System has access to an Excel workbook that contains valuable information about your hospital’s compliance with myriad Medicare...more

Sheppard Mullin Richter & Hampton LLP

Are You Ready for 2023? Here’s a Quick Checklist to Reduce Legal Risks in the New Year

The New Year energizes us to plan for success in the coming months. To increase the odds of meeting your business goals, we suggest taking a quick inventory of legal risks and brainstorming corrective actions for 2023...more

Polsinelli

Ten Individuals Charged in Business Email Compromise Scheme Targeting Medicare, Medicaid and Other Insurers

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On November 18, 2022, the U.S. Department of Justice (“DOJ”) announced charges against ten defendants across Georgia, South Carolina and Virginia, resulting from a scheme that allegedly targeted Medicare, state Medicaid...more

Arnall Golden Gregory LLP

Should You Keep the Medicare Provider Relief Funds and If So, What are the Compliance Risks?

On April 10, 2020, the Department of Health and Human Services (DHHS) released the first $30 billion portion of the $100 billion stimulus fund intended to provide financial relief to healthcare providers during the COVID-19...more

Robinson & Cole LLP

Data Privacy + Cybersecurity Insider - March 2018 #2

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Cybersecurity Task Force Launched in Arizona - Arizona Governor Doug Ducey launched the Arizona Cybersecurity Team (ACT) by Executive Order on March 1, 2018. The ACT is comprised of 22 members representing officials from...more

Foley & Lardner LLP

Health Care Rep and Warranty Insurance: New Solutions for Private Equity Buyers and Sellers

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Whether in an auction or proprietary transaction, risk allocation has typically been a function of indemnities tied to reps and warranties and the type of credit supporting the type of supporting credit. Holdbacks, earnouts,...more

Cozen O'Connor

ACOs And Pay for Value … About the Data

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It has been over three years since the Centers for Medicare and Medicaid Services (CMS) announced its proposed rule and guidance on the development and implementation of Accountable Care Organizations. About four million...more

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