Federal agencies are escalating their fight against alleged fraud, waste and abuse in Medicare and Medicaid, deploying funding freezes, new enforcement units and criminal prosecutions. Here are 10 numbers that define the crackdown. $2 billion. The amount CMS could withhold…
ASC Coding, Billing & Collections
Two Massachusetts physicians and their shared practice have been indicted on charges of illegally prescribing controlled substances without legitimate medical purpose and submitting false claims to Medicaid, the Massachusetts Attorney General’s Office said in a May 26 news release. Jeffrey…
Since March 24, the Justice Department has sentenced, accused or settled with four physicians and four durable medical equipment company owner for fraud cases. The activity comes as CMS is currently enforcing a six-month nationwide moratorium on new Medicare enrollment…
A former Connecticut advanced practice registered nurse has been arrested on charges of submitting more than $1.35 million in fraudulent Medicaid claims for medication management services never rendered, the Justice Department said in a May 22 news release. Marisol Rodriguez,…
Prior authorization has been under intense scrutiny in recent months as frustration brews among clinicians and legislators aim to curb the use of AI technology in the practice. Here are five recent developments reshaping the way prior authorization is deployed…
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Allstate has filed three federal lawsuits against ASCs and their affiliated providers since mid-April, alleging schemes ranging from kickback arrangements and corporate practice violations to billing for procedures that were never performed. 1. Allstate sued Florida Orthopedics and Neurosurgery, which…
Stark law was written before the internet, EHRs or AI-driven diagnostics existed. But it is still dictating how physicians can structure financial relationships in 2026, and a growing chorus of physicians, legal experts and industry groups say it is time…
CMS’ 2026 Hospital Outpatient Prospective Payment System rule moves Medicare further toward site-neutral payment, as part of an effort to narrow long-standing payment gaps between hospital outpatient departments and ASCs. In the 2026 final rule, CMS also finalized site-neutral payment…
Major payers are quietly cutting reimbursement by automatically adjusting the complexity codes on claims before payment clears. In the past year, Cigna, Aetna, Anthem and BCBS of Massachusetts have all launched or expanded automatic downcoding programs, algorithmically adjusting higher-complexity E/M…
For independent ASCs, the economics of survival have never been more precarious. Reimbursement rates have not kept pace with inflation, staffing costs have surged and some commercial payers have effectively closed the door on negotiations. Suzi Cunningham knows this reality…