Archive for January 2019
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…
Read MoreCourt 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…
Read MoreGovernment 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…
Read MoreThe 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)…
Read MoreHow 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…
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