The Texas Health and Human Services Commission (HHSC) passed new and consolidated rules on October 14, 2012. According to the OIG’s counsel, the new rules increase the likelihood of litigation, increase revenue for the state, lower the State fiscal burden and increase the State’s ability to exercise a sanction on providers.
On December 1, 2011…

The heads of both the Department of Justice (DOJ) and Department of Health and Human Services (HHS) sent a joint letter on Monday, September 24, to five hospital industry groups, including the American Hospital Association, threatening to prosecute providers that use electronic health records (EHR) to “game” the system and improperly obtain federal monies for…

In less than two weeks, CMS will begin reducing a hospital’s Medicare reimbursements by as much as 1% if the hospital’s readmission rates are too high.  This reduction is part of a program authorized by the Affordable Care Act called the Hospital Readmissions Reduction Program.  You can read more about the program CMS’s website.

Nearly 1…

In August, the Office of Inspector General (OIG) of the U. S. Department of Health and Human Services released a report describing inappropriate and questionable billing by home health agencies.  The OIG conducted the study because recent investigations and studies showed that home health agencies are vulnerable to fraud, abuse, and waste.  The OIG identified inappropriate claims by examining claims data from home health, inpatient hospital, and skilled nursing facilities.  The OIG also looked at HHAs that billed unusually high amounts according to at least one of its six measures of questionable billing.  The report determined that Medicare inappropriately paid $5M for home health claims with three specific errors in 2010.  To read the report, click here.

Attorney Elizabeth Hogue prepared a concise, helpful summary of the report as follows:

The OIG issued Report OEI-04-11-00240 in August, 2012, entitled “Inappropriate and Questionable Billing by Medicare Home Health Agencies.” Unlike some other guidance published the OIG, this Report provides detailed information about inappropriate and questionable billing practices by home health agencies (HHA’s). Specifically, the OIG concluded that HHA billing is questionable or unusually high on the six measures below, if greater than the 75th percentile plus 1.5 times the interquartile range. The six measures are as follows:

 1. High average outlier payment amounts per beneficiary

According to the OIG, HHA’s with outlier payments above $403 per beneficiary have unusually high outlier payments and are likely engaging in questionable billing practices.


Earlier this month, the US Dept. of Health and Human Services Office of inspector General (OIG) issued a report regarding suspicious billing practices by community mental health clinics (CMHCS).  OIG scrutiny of CMHCs, particularly with respect to partial hospitalization programs (PHPs), is probably not a surprise to those in the Texas mental health provider community…

Recently, the United States Court of Appeals for the Second Circuit heard arguments on whether lawyers are allowed to bring whistleblower lawsuits against their employer and client (U.S. ex rel. Fair Laboratory Practices Associates vs. Quest Diagnostics Inc. et al.).  A U.S. District Court threw out the case in April of 2011, ruling that…

Last week, Paul Ryan accepted the nomination for Vice President.  In his acceptance speech, he cited “Obamacare” as the greatest threat to Medicare, but many hospitals view the expansion of coverage for low-income individuals positively.  More and more community hospitals are urging their state governments to accept payments for expanded Medicaid programs under the…

On August 10, 2012, HHSC-OIG posted proposed regulations that would expand the power and reach of the Office of Inspector General.  These regulations broaden the net so that persons who are affiliated with a provider can be sanctioned along with a provider as a result of such affiliation, and “affiliate” is broadly defined.  These regulations…

The FTC recently provided yet another warning to healthcare organizations that they must take the time to analyze potential antitrust implications when considering an acquisition or consolidation.  On August 6, the FTC  and Nevada Attorney General announced the filing of a lawsuit and proposed consent decrees settling litigation filed against Renown Health, the largest hospital provider in…

HHSC is performing certification/recertification review of all Durable Medical Equipment (DME) providers.  Over the past few weeks HHSC has been making site visits to Medicaid enrolled DME suppliers to verify operations and enrollment data.  Medicaid DME suppliers must cooperate with the HHSC investigators; a failure to do so may result in termination of a supplier’s…