Last summer, I wrote about the Department of Justice (DOJ) and Department of Health and Human Services (HHS) launching a joint False Claims Act Working Group focused on Medicare fraud enforcement. At the time, the government identified several priority enforcement areas, including Medicare Advantage risk adjustment, kickbacks, drug and device arrangements, and the use of
Aetna Agrees to Pay $117.7 Million to Settle False Claims Act Allegations Over Medicare Advantage Upcoding
Last summer, I wrote about the DOJ and HHS relaunching their joint False Claims Act Working Group, with Medicare Advantage risk adjustment fraud listed as one of its top enforcement priorities. The Aetna settlement announced earlier this month is a direct example of that initiative delivering results.
What Happened
Aetna has agreed to pay $117.7
CMS Launches ASC Prior Authorization Demo for Certain “High-Risk” Procedures: What ASCs and Surgeons Need to Know
The Centers for Medicare & Medicaid Services (CMS) has been using prior authorization for selected Hospital Outpatient Department (OPD) services for several years as part of its broader effort to curb improper payments and unnecessary utilization. In late 2025, CMS expanded that approach into the Ambulatory Surgical Center (ASC) setting through a new Prior Authorization
What the Government Shutdown Means for Physicians
As of October 1st, the federal government is officially shut down after Congress failed to pass funding legislation. While the biggest direct impact will certainly be on furloughed federal workers and government agencies, if your practice relies on Medicare or Medicaid, or you are involved in research, there are ripple effects worth understanding.
What Stays
Update: HIPAA Final Rule on Reproductive Health Privacy
The U.S. Department of Health & Human Services (HHS) issued a Final Rule in April 2024 amending the HIPAA Privacy Rule to strengthen protections for reproductive health care information. The goal was to prevent medical records from being used to investigate or penalize patients or providers for seeking or offering lawful reproductive care.
However, in
CMS Unveils 2026 Physician Fee Schedule Proposal: Key Changes Ahead
On July 14, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2026 Physician Fee Schedule. As expected, there are several meaningful updates that providers, practices, and health systems should be aware of.
One of the more significant changes is that CMS will split the conversion factor into two separate
2022 Federal Compliance Enforcement Outlook
There is almost universal agreement regarding predictions for 2022 federal enforcement in the following areas:
- The use of fraudulently obtained COVID relief funds in both healthcare and in general, but specifically as a foundation for False Claims Act enforcement.
- Furthermore, the reinstatement of the Yates memo of 2015 by the Deputy Attorney General Lisa Monaco’s
CMS Posts Open Payment Data – $7.52 Billion in 2015
CMS published the 2015 Open Payment Data on June 30, 2015. This is the link to the notice and the CMS site: https://openpaymentsdata.cms.gov/
CMS has presented tables in its press release showing the highest paid specialties and highest paying companies. Over the last two years, Novartis has paid approximately $842 million to 344,000 recipients, which
Final 60 Day Overpayment Rule
CMS has issued the final regulations to implement that section of the Affordable Care Act amending the Social Security Act to provide that retention of identified overpayment could be a false claim and be subject to both the False Claims Act (FCA) and the Civil Money Penalty Act (CMP).
ACA § 6402(a) established new Social
Physician Practices Face Anti-Trust Risks, Too
On December 18, 2015, the Federal Trade Commission (FTC) announced a settlement with Keystone Orthopaedic Associates Specialists and Orthopaedic Associates of Reading, LTD, which were two of six orthopedic practices in Berks County, Pennsylvania that merged in 2011.
The FTC initiated the Complaint because they believe the merger of the practices eliminated competition among orthopedists