By David A. Zarett, Esq.Email David It has become commonplace for physicians and medical practices to face audits and payment reviews by commercial health insurers and third-party administrators (“TPAs”) under an ERISA plan. If an overpayment is identified, it is not unusual for the carrier or TPA to recoup the funds allegedly owing. One of […]
Continue reading…Understanding The Medicare Fraud Investigation
By Mathew J. Levy, Esq.Email the Author Today, the sensationalized stories of FBI agents and criminal indictments are the day to day realities of Medicare enforcement faced by every physician. What is Medicare Fraud? First, there are the obvious cases of greed, such as physicians billing for fictitious patients and services never performed and the rendering […]
Continue reading…New Guidance Issued by Medicare Involving Extrapolation
By Mathew J. Levy, Esq. & Stacey Lipitz Marder, Esq.Email Mathew Email Stacey In today’s healthcare climate, many providers have been subject to an audit by Centers for Medicare & Medicaid Services (CMS) whereby CMS (through one of its contractors) requests a sample of records and subsequently determines that the documentation does not substantiate the […]
Continue reading…Featured in the Journal of the Nassau County Bar Association June 2018: Understanding the Legal Implications Involving Management Services Organizations
By Mathew J. Levy, Esq. Email Mathew Introduction Management Services Organizations (“MSOs”) can provide real and appreciable benefits to busy practitioners, allowing them to provide better patient care, unencumbered by the demands of micromanaging the business. MSOs can also be a productive venture for those who own and operate them. The ability to provide a […]
Continue reading…Understanding Third Party Payor Audits Affecting Physicians
By Mathew J. Levy, Esq. & Stacey Lipitz Marder, Esq.,Weiss Zarett Brofman Sonnenklar & Levy, P.C. Email the Author SERIES DESCRIPTION: There is perhaps no more frustrating moment in a physician’s career than when a health plan or managed care company notifies him/her that, after the physician has spent countless hours and expended endless efforts […]
Continue reading…Understanding EUOS and New Guidance Involving Corporate Structure
By: Mathew J. Levy, Esq. & Stacey Lipitz Marder, Esq.Weiss Zarett Brofman Sonnenklar & Levy, P.C.Email the Author Providers rendering services under No-Fault are probably familiar with Examinations Under Oath (EUOs). As per applicable No-Fault regulations, by accepting a patient’s assignment of benefits, an insurance company may demand that a provider appear before an EUO […]
Continue reading…Medicaid Fraud Control Unit Alleges Illegal Fee-Splitting by New York Physicians in Billing Vendor Arrangements
By David A. Zarett, Esq.Email David Recently, physicians in the Central New York and Adirondack areas were contacted by the Medicaid Fraud Control Unit of the New York State Attorney General’s Office (“MFCU”) demanding repayment of Medicaid funds allegedly paid under a fee-splitting arrangement. In short, MFCU claims that the physicians paid a percentage of Medicaid […]
Continue reading…OIG’s New Civil Monetary Penalties Regulations Offer Insight into the Agency’s Decision-Making Process
By: David A. Zarett, Esq. and Lijia Sanchez, Esq.Weiss Zarett Brofman Sonnenklar & Levy, P.C. Effective January 6, 2017, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HSS) issued a final rule that restructures its civil monetary penalty (CMP) regulations, shedding light on the agency’s review process in […]
Continue reading…Office Based Surgical Procedure Audits – How to Handle Them
By Mathew J. Levy, Esq.Email Mathew Regrettably, many physicians are receiving a letter from an insurance carrier informing the physician that the physician must repay a substantial amount of money as a result of what has been billed to the insurance carrier and paid without objection. Perhaps the most frustrating part of all is that […]
Continue reading…Understanding How to Respond to a Visit From an Investigator
By Mathew J. Levy, Esq. & Stacey Lipitz Marder, Esq.Email Mathew Email Stacey Introduction: As the government and private payors continue to invest resources into combatting fraud and abuse in the healthcare system, many practices are being faced with unexpected visits from state and federal government and private investigators, including but not limited to investigators […]
Continue reading…Understanding Prepayment Audit Reviews
By: Mathew J. Levy, Esq. & Stacey Lipitz Marder, Esq.Email the Author Overview: The unfortunate reality is that the cost of running a medical practice is increasing while reimbursement from third party payers is decreasing. In order to survive, it is crucial that physicians get paid for the services rendered to their patients in a […]
Continue reading…Retrospective Audits: How to Avoid Them
By: Mathew J. Levy, Esq.Email the Author There is perhaps no more frustrating moment in a physicians career than when a health plan or managed care company notifies them that, after the physician has spent countless hours and expended endless efforts to get paid fifty or sixty cents on the dollar, the payor is now […]
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