Monthly Newsletter

August 2021 Monthly Newsletter

Who is Responsible for Health Care Data Breaches?

The Office for Civil Rights (OCR), HIPAA enforcement agency, announced that the results found in a recent report analyzing health care sector data breaches indicate:

  • 61% were perpetrated by external threat actors; and
  • 39% by insiders (your workforce)

The rise in data breaches due to hacking as well as threats to ePHI by malicious insiders highlight the importance of establishing and implementing appropriate policies and procedures regarding Security Rule requirements. Ensuring that workforce members are only authorized to access the ePHI necessary and that technical controls are in place to restrict access to ePHI can help limit potential unauthorized access to ePHI for both threats. 

Sending “Surprise” Medical Bills to Patients? Think Again

Government Announces the No Surprises Act to Protect Patients

Tackling surprise billing has become a priority due to government studies demonstrating the devastating financial consequences for individuals and their families. Two-thirds of all bankruptcies filed in the United States are tied to medical expenses, according to a citation used by DHHS from a report made by CNBC.  Researchers estimate that 1 of every 6-emergency room visits and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medical bills.

"Requirements Related to Surprise Billing; Part I," an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan's network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.  Read the Fact Sheet.  Know the rules – get certified in Revenue Cycle Management online, on-demand.

U.S. Dept of Labor – Final Rule Rescinds Earlier Rule

Final Rule Effective September 28, 2021

On July 29, 2021, the Department of Labor announced the Rescission of Joint Employer Status Under the Fair Labor Standards Act Rule.  The earlier rule from March 2020, “Joint Employer Status under the Fair Labor Standards Act” being rescinded ensures more workers receive minimum wage and overtime protections of the Fair Labor Standards Act.

A strong joint employer standard is critical because FLSA responsibilities and liability for worker protections do not apply to a business that does not meet the definition of employer.  The rule is published in the Federal Register on 7/30/2021 (click here for the unpublished PDF version). Click Here for the Federal Register Wage & Hour Division page.

COVID Emergency Use Authorization (EUA) for Tocilizumab

On June 25, 2021, the Federal Government is immediately pausing all distribution of bamlanivimab and etesevimab together and etesevimab alone (to pair with existing supply of bamlanivimab at a facility for use under EUA 094 on a national basis until further notice. In addition, FDA recommends that health care providers nationwide use alternative authorized monoclonal antibody therapies, as described below, and not use bamlanivimab and etesevimab administered together at this time.

CMS created new codes for inpatient administrations (listed below).  Billing Note: You can’t use the Roster Bill form to report multiple units or infusions. Submit individual claims for the tocilizumab product and infusions when reporting multiple units of the product and/or the first and second infusions.

Tocilizumab for covid-19

Q0249   Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

Tocilizumab for covid-19 First Dose

M0249  Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose

Tocilizumab for covid-19 Second Dose

M0250  Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose.

Download the FDA Fact Sheet to share with your providers. Click Here for the CMS Monoclonal Antibody Infusion webpage

It is Hurricane Season – OSHA Presents COVID-19 Preparedness & Response Resources

OSHA’s preparedness page outlines the warnings and watches used for hurricanes, including the five categories used to rate the strength of a hurricane. The page also contains information on creating evacuation plans and supply kits. The Response/Recovery page features a link to OSHA’s Hurricane eMatrix, which features information on hazard exposures and risk assessments for hurricane response and recovery work.


What’s Trending - Significant Fraud Schemes Harming Patients

Why review recent fraud schemes? 

Staying aware of criminal cases, in addition to monitoring the OIG Work Plan, helps Auditors, Forensic Auditors and Compliance Officers stay aware of potential risks that could be happening within your own organization.

$86 Million Fraudulently Billed to Medicare

Owner Of Spring Hill-Based Crestar Labs, LLC Charged In Massive Medicare Fraud Scheme

Alleged Illegal kickbacks in exchange for solicitation of genetic testing from Medicare beneficiaries.

$38.75 Million Paid to Settle False Claims Act Allegations

Medical Device Companies pay to settle allegations for knowingly selling defective INRatio blood monitors

Since at least 2008, Alere Inc. and Alere San Diego Inc. (collectively, Alere), allegedly knew that the software algorithm used in each version of its INRatio monitors contained a material defect. The United States alleged that, despite awareness that INRatio systems were linked to over a dozen deaths and hundreds of injuries, including intra-cerebral hemorrhaging and cardiovascular events following bleeding episodes, Alere concealed the defect for years and billed Medicare for the use of defective INRatio devices.

$27 Million Paid by St. Jude for Allegedly Selling Defective Heart Devices

St. Jude failed to disclose serious adverse health events

St. Jude Medical Inc. (St. Jude) has agreed to pay $27 million to settle allegations under the False Claims Act that, between November 2014 and October 2016, it knowingly sold defective heart devices to health care facilities that, in turn, implanted the devices into patients insured by federal health care programs. St. Jude was acquired by Abbott Laboratories in January 2017.

$26 Million Recovered by AG for Texas Medicaid Program

Pharmaceutical manufacturer Apotex caught reporting inflated drug prices to the Texas Medicaid program

Under the agreement under Attorney General Ken Paxton, Apotex will pay Texas $26 million to resolve claims against it related to inflated drug prices.

$21 Million to Resolve FCA Allegations for Improper Payments to Referring Physicians

Akron General Health System (AGHS), Pays to Resolve Stark and Anti-Kickback allegations

AGHS is a regional hospital system based in Akron, Ohio, is paying $21.25 million to settle allegations under the False Claims Act of improper relationships with certain referring physicians, resulting in the submission of false claims to the Medicare program.  GHS paid compensation substantially in excess of fair market value to area physician groups to secure their referrals of patients, in violation of the Anti-Kickback Statute and the Physician Self-Referral Law, and then submitted claims for services provided to these illegally referred patients.

$20 Million and 6-Years Federal Prison for Florida Physician for DME Scheme

Dr. Richard Davidson has been sentenced to six years in federal prison for conspiracy to commit health care fraud

As part of his sentence, the court ordered Davidson to forfeit approximately $650,000 in funds traceable to the offense or as substitute assets. The court also entered a money judgment of $2.47 million and ordered $10.72 million in restitution. Davidson lost his medical license due to his conviction.

Internal Forensic Auditor

Learn How to Conduct Internal Investigations

Earn your CIFHA (Certified Internal Forensic Healthcare Auditor) credential online.  Member Pay Only $995 (payment plans available).  Non-members pay $1,500.  Tuition includes all online training materials, mock and certification exam.

Certification exam is taken safely online with a trained, remote proctor timed at 3 hours.  Learn More - watch the video - register and start today!


3 Live Training Events


Training Camp

October 6-7, 2021 Tampa, FL


Training Camp

October 20-21, 2021 Nashville, TN


Training Camp

October 26-27, 2021 Las Vegas, NV

Train & Certify Online as an Outpatient Clinical Appeals Specialist

Appeals Management

Earn your COCASSM (Certified Outpatient Clinical Appeals Specialist) credential online. No classes to attend but you do have access to qualified, experienced instructors on-demand. Most experienced working in outpatient Patient Financial Services, Revenue Cycle Management, Accounts Receivables, Medical Coding and/or Billing complete this training in 6-8 weeks, but you have 12 weeks (and more time you can purchase) to complete the course and an addition 3 months to certify.

Certification exam is taken safely online, timed at 3 hours, has 100 questions and scheduled with a professional remote Proctor.

Learn More - watch the video - register and start today!

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