This webinar will focus on cases and enforcement actions taken by the HHS OIG and its law enforcement partners in 2021.
We will also briefly review the Anti-Kickback Statute (“AKS”), discuss safe harbors, particularly the new proposed safe harbor for coordinated care and associated value-based arrangements, and OIG Advisory Opinions that have been issued in 2021, as well as pertinent cases involving the AKS.
This program is designed for healthcare executives, physicians, and other healthcare providers and their managers who participate in and receive remuneration from Medicare, Medicaid, and other federal healthcare programs such as TriCare. Several recent cases bring home the realization that many activities that are common in other industries are a crime under federal healthcare fraud and abuse laws.
Hospital executives, as well as physicians and/or other health care providers, should be very concerned about the potential for the government to use the AKS as one of the prime methods for enforcing federal fraud and abuse laws. Equally concerning, along with Stark II (the federal physician anti-referral law), the AKS can be and is being used as the basis for an action brought under the Federal False Claims Act.
In this webinar, you will learn about the elements of the AKS, along with the various exceptions and safe harbors that you can rely on for protection against enforcement under these laws. This is important because healthcare fraud and abuse if becoming the focus of these enforcement efforts.
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The session will provide an overview of the Federal Civil False Claims Act (FCA) and how it works. It will also provide an assessment of enforcement activities, showing how healthcare providers may be at risk. In addition, the session will review recent cases and show how they potentially impact healthcare providers.
We will start with a review of the Federal False Claims Act and discuss how it works and how it is being used to fight health care fraud. We will discuss how the various health care fraud task forces use the Federal False Claims Act and its whistleblower provisions
to identify and prosecute health care fraud. The webinar will take the Federal False Claims Act apart and show step by step how an action is filed, how the government responds and how the courts interpret various elements of the Act. We will discuss proof, damages under the Act and how the whistleblower is rewarded for bringing a successful case.
The session will also provide an overview of the Anti-Kickback Statute (AKS) and review what it prohibits, as well as a general review the AKS available safe harbors. It will also show how violation of the AKS can raise FCA concerns, and it will provide an assessment of enforcement activities, showing how participants may be at risk. In addition, the session will review recent cases and show how they potentially impact participants.
We will provide an in-depth review of the AKS, focusing on what is prohibited under the Act and what the exceptions are. We will also review the case law, particularly the early case law that sets the stage and basis for how the courts interpret the law.
We will also review the changes made to both the False Claims Act and the AntiKickback Statute made by the Affordable Care Act.
Finally, the webinar will review various cases to show how easy it is to run afoul of the Statute, and how the courts view compliance with it. In addition, we will discuss the latest updates to both the False Claims Act and the Anti-Kickback Statute.
Recent cases and/or enforcement actions involving the FCA raise serious concerns regarding compliance issues with hospital, physician practices and other healthcare entities. Recoveries under the FCA are at an all-time high, and the percentage of actions involving healthcare organizations has been increasing at exponential rates.
This session is designed for healthcare executives, attorneys and consultants who advise health care executives and others who want to learn about the False Claims Act. The health care executive, physician or other health care provider, should be very concerned about the potential for enforcement actions under the FCA. This is important because under recently enacted health care laws, enforcement and health care fraud task forces have been greatly enhanced. Recovery under the FCA last year resulted in over $3.1 billion being recovered for the federal government, $24.2 billion since the law was revised to make it more relator friendly in 1986.
In FY 2020, the Department of Justice (DOJ) opened 1,148 new criminal health care fraud investigations. Federal prosecutors filed criminal charges in 412 cases involving 679 defendants. A total of 440 defendants were convicted of health care fraud related crimes during the year. Also, in FY 2020, DOJ opened 1,079 new civil health care fraud investigations and had 1,498 civil health care fraud matters pending at the end of the fiscal year. Federal Bureau of Investigation (FBI) investigative efforts resulted in over 407 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 101 health care fraud criminal enterprises. In FY 2020, investigations conducted by HHS’s Office of Inspector General (HHS-OIG) resulted in 578 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 781 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider selfdisclosure matters. HHS-OIG also excluded 2,148 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.
Since 1986, whistleblowers have been awarded nearly $4 billion and whistleblowers are where a majority of the FCA suits originate. Several recent cases involving healthcare providers have resulted in huge settlements. If that is not enough to get your attention, consider the recent cases finding that the “responsible corporate officer doctrine” allows the government to hold hospital CEOs and others directly responsible for the fraud. In a recent case, executives paid $1 million to settle allegations of fraud and were excluded from participation in federal health care programs. You will want to attend this webinar to learn how to protect your healthcare providers.
Venue: Recorded Webinar
There are several parts of seeing a patient and receiving payment for professional services. Eligibility ensures that the patient’s insurance coverage is active on the date of service that the services will be rendered and that their plan covers the services planned. There are different methods of receiving eligibility information and we are going to discuss these. Once eligibility is verified, certain procedures require the provider to contact the insurance company to receive prior authorization. Unfortunately, every insurance company has different requirements, making it difficult to manage. It is important that offices keep track of the current policies for the insurance companies they work with the most, and ensure these authorizations are performed prior to the service being performed. Medical necessity is normally reported by the ICD-10-CM codes. These codes justify why a procedure or service is performed based on the patient’s condition. The insurance companies may have policies that define the services they consider medically necessary based on the diagnosis. If the information on the claim does not meet their guidelines, the claim will be denied. Insurance companies are requiring that authorization for services be obtained for more services and procedures. It is also common that employers will change insurance plans to save money on monthly premiums. This session will walk through how offices can obtain eligibility before the patients are seen to confirm that the insurance information that is available is accurate and the patient is covered for services to be rendered. Then when the patient is seen, any services or procedures that are ordered may need to be prior authorized for that reimbursement will be received. The final piece is that the medical necessity requirements for the procedure or service is being met according to insurance company policies and guidelines. Attendees will benefit from this webinar in that we will discuss all of these aspects of a medical claim that may have to occur before the insurance company even processes it and will reduce the number of claims an office can receive because these steps were not taken. Methods available for eligibility When is the best time to verify eligibility Know when prior authorization is needed Getting authorization for special circumstances What to do when prior authorization has to be changed Why does medical necessity play a role in reimbursement There is never a guarantee of payment
ICD-10-CM updates for 2025 will become effective on October 1, 2024. These updates will include several guideline changes as well as multiple updates & additions to the specific chapters. This webinar will discuss the new guidelines as well as specific code categories in which you need to be alert to changes that may impact your code selection. All chapters will be included to ensure your specialty is covered. It is important that you be proactive and prepared when submitting your claims with discharge dates of October 1. Missed update information may cause a processing & reimbursement delay. Webinar’s Goals Be aware of guideline changes Learn about chapter specific additions & updates Ensure you are prepared with new code information Align with your software vendors to implement any necessary changes Target Audience Revenue Cycle Managers & staff Billers Coders Clinical Documentation Staff Finance Managers Denial Management Staff Physicians Mid Level Providers Claims Follow Up Staff
Critical Access Hospitals (CAHs) must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation located in Appendix W in the manual. This eight-part webinar series will cover the CAH CoP manual. There were changes and new regulations for CAHs in 2020, including a change to all the tag numbers, some which do not include Interpretive Guidelines or Survey Procedures. Changes include infection prevention and control and antibiotic stewardship, QAPI and Swing Bed changes. This seminar will help CAHs comply with specific CoP problem areas, such as nursing care plans, necessary policies and procedures, medication administration and drug storage, and informed consent to name a few. Part Three of Eight: Physical Plant & Environment, Emergency Preparedness Objectives Describe expectations for a safe environment for patient care Recall the requirements for equipment maintenance and an alternative management program Explain the importance of maintaining ventilation, temperature, and lighting within a CAH Describe the mandatory training and exercises for an emergency preparedness plan Physical Plant and Environment Construction and maintenance Equipment, preventive maintenance and AEM Physical environment Disposal of trash Storage of drugs Life Safety from Fire LSC waivers Fire inspections Emergency Preparedness Emergency Plan Policies and procedures Communication Plan Training and testing Power systems Appendix and Resources
Calling all medical coding professionals, CDI and auditors, it’s that time again! Join us as we take a deep dive on all updates related to the Official Guidelines for Coding and Reporting for fiscal year 2025. Together, we will be evaluating all affected diagnosis codes which includes additions, deletions and revisions. Knowledge is power so let’s be proactive and review our updated guidelines to ensure quality reporting, accuracy, compliance and proper reimbursement. Webinar Objectives Review the changes to the Official Guidelines for Coding and Reporting FY 2025 Know diagnosis codes that were deleted, added and revised in each affected chapter Understand documentation best practices in impacted diagnosis codes Questions and Answers Who Should Attend HIM Coding Directors, Managers, Supervisors Hospital Coding Staff Clinical Documentation Improvement Management and Staff Reimbursement Specialists Coding Compliance Management and Staff Auditors and Educators