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HHS Proposes Changes to Drug Rebate Safe Harbors

The U.S. Department of Health & Human Services (HHS) has issued a proposed rule that would amend the safe harbor regulation for certain drug rebates that manufacturers pay to pharmacy benefit managers (PBMs) Medicare Part D, and Medicaid managed care organizations (MCOs). Published in the Federal Register on February 6, the proposal is designed to […]

Lab to Pay $63.5M to Settle Kickback Allegations

Inform Diagnostics, an Irving, Texas-based pathology laboratory company, has agreed to pay $63.5 million to settle allegations that it violated the False Claims Act by engaging in improper financial relationships with referring physicians. The settlement stems from allegations that the company violated the Anti-Kickback Statute and the Stark Law by providing referring physicians with subsidies […]

OIG: Pediatric Clinic Can Provide Routine Cost-Sharing Waivers

A pediatric clinic that provides medical, psychiatric and dental care to low-income children can waive cost-sharing amounts for patients in financial need, even though the arrangement does not meet the regulatory exception for permitted waivers of cost-sharing amounts under the Civil Monetary Penalties Law, according to an Advisory Opinion issued by the Health and Human […]

Court Rules Against United’s Offsetting Policy

UnitedHealth Group’s policy of withholding payments to out-of-network physicians and doctors in order to recover previous overpayments – a practice known as cross-plan offsetting – is not permissible and may even violate The Employee Retirement Income Security Act (ERISA). That was the long-awaiting ruling from the Eighth Circuit Court of Appeals issued last week. The […]

Government cracking down on drug company ties to charities

Actelion Pharmaceuticals, a San Francisco-based biopharmaceutical company, recently agreed to pay $360 million to resolve allegations it provided kickbacks to a charitable organization through contributions it made, and that the charity turned around and used those contributions to pay the copays of patients using Actelion’s drugs. Drug makers are not permitted to make Medicare patient […]

The Granston Memo One Year Later

Last year, we wrote about an internal memo from the U.S. Department of Justice addressing the dismissal of qui tam (whistleblower) cases. The Granston Memo, so named because it was written by DOJ’s Director of Civil Fraud Section Michael Granston, outlined various factors government prosecutors should use to evaluate whether a False Claims Act (FCA) […]

How Artificial Intelligence is Detecting Healthcare Fraud

Throughout 2018, we saw how the federal government cracked down on healthcare fraud using a variety of technological advances As we have written about over the years, data analytics is increasingly being used to identify inappropriate payments. Through data mining and the use of predictive analysis, thousands or even millions of transactions, can be searched […]

Hospital Fails to Terminate Former Employee’s Access to HIPAA-Protected Data

A recent HIPAA enforcement action should serve as a reminder to healthcare organizations of the need to terminate an employee’s access to patients’ electronic protected health information (ePHI) immediately after that employee leaves the organization. The most recent action – the third within a month – involved Pagosa Springs Medical Center in Colorado. The critical […]

Watchdog Report: Nearly $3B Recovered From Providers

Fighting healthcare fraud remains among the priorities for the U.S. Department of Health and Human Services Office of the Inspector General as evidenced by its most recent semiannual report to Congress. The watchdog organization reported recovering $2.91 billion from providers in fiscal year 2018. It took criminal actions against 764 individuals or healthcare providers that […]

Failure to Have Business Associates Agreement in Place Proves Costly

 A medical group practice based in Lakeland, Fla. must pay $500,000 to settle potential HIPAA violations and adopt a substantial corrective action plan after a data breach that could have affected more than 9,000 patients was discovered. According to the Office for Civil Rights of the U.S. Department of Health and Human Services, between November […]

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