Monthly Newsletter

April 2024 Monthly Newsletter

OIG Impact Brief

Medicare Advantage Prior Authorization

Medicare Advantage Organizations (MAOs) issue more than 1 million denials each year, and in 2019, an estimated 13 percent were for services that were medically necessary for the patient, according to the Office of Inspector General (OIG).  The Centers for Medicare and Medicaid Services (CMS) issued regulatory changes in January 2024 and April 2023 which 1) decrease delays in care; and 2) prevent inappropriate denials of care.  Download the Impact Brief published by the OIG on March 18, 2024 for links to more information.

Quality & Safety in Telemedicine

Is your practice interested in improving appropriate use of antibiotics in telemedicine?

Infection-related complaints account for a large proportion of telemedicine visits.  The Agency for Healthcare Research and Quality (AHRQ) reports that two million infections per year are caused by antibiotic resistant organisms, leading to 35,000 deaths per year in the United States. Meanwhile, one-third of outpatient antibiotic prescriptions and half of the prescriptions for acute respiratory infections are unnecessary.


Participate!  AHRQ is currently recruiting practices for a no-cost, 18-month program beginning in June 2024 to promote appropriate antibiotic use while maintaining patient satisfaction and reducing potential side effects in patients seen via telemedicine.  Click Here for more information about the program and to enroll.  Enrollment ends May 23, 2024.

Suicide Prevention Following Hospital Discharge

Findings reveal significant gap in implementation of recommended practices

According to a recent study, “Every year in the United States, an estimated 49 to 65 hospitalized patients die by suicide. and multiple studies suggest that the risk for suicide is significantly higher following discharge.”  The Joint Commission's National Patient Safety Goal (NPSG) for suicide prevention (NPSG.15.01.01) requires accredited hospitals maintain policies/procedures for follow-up care at discharge for patients identified as at risk for suicide.

Now a study has been published in The Joint Commission Journal on Quality and Patient Safety (JQPS) which was funded by Pew Charitable Trusts.  This study evaluated the prevalence of four suicide prevention activities following hospital discharge among Joint Commission-accredited hospitals:

  • Formal safety planning
  • Planning for lethal means safety
  • Providing warm handoffs to outpatient care (a medical professional introducing a patient to a behavioral health clinician and initiating contact prior to discharge)
  • Making follow-up contact after discharge

Read the study posted to the Joint Commission Journal on Quality and Patient Safety website.

Covered Entity Decision Tool

Not sure if you’re a covered entity? 

Did you know that HIPAA (Health Insurance Portability and Accountability Act) covered entities must also comply with standards for electronic transactions – not just privacy and security provisions?


The Centers for Medicare & Medicaid Services (CMS) offers a tool to help health care providers and organizations check whether or not they are considered HIPAA covered entities, such as Health Plans, Clearinghouses and Providers. Download the CMS Covered Entity Decision Tool.

EMTALA Violations can be Costly & Damage Your Reputation

Recent Violations of the Patient Dumping Statute


Jackson Health System in Miami Florida is paying $233,000 to resolve OIG allegations of violating of the Emergency Medical Treatment and Labor Act (EMTALA).  The investigation revealed a patient died in the Jackson South Emergency Department (ED) of complications of novel coronavirus infection after waiting approximately 10 hours without triage or a medical screening examination.  Read more about this case.


UF Health Shands Hospital of Florida pays a settlement of $199,942 to resolves alleged EMTALA violations. The OIG investigation revealed failure to evaluate and stabilize a patient who was in UF Health’s waiting room for approximately 16 hours.  The patient was found unresponsive in the Emergency Department (ED) waiting room and staff were unable to resuscitate him.  Autopsy results showed that he died of a ruptured aneurysm. Read more about this case.


Starr Regional Medical Center in Tennessee is paying $100,000 to settle OIG allegations of failing to perform an adequate medical screening examination or to stabilize a patient’s emergency medical condition.  The patient presented with complaints of low back pain, pelvic pain, hematuria, and pain at a level of 9 out of 10.  The ED doctor ordered a pregnancy test, which later came back positive.  However, her discharge occurred before the HCG test results were available. Approximately 9 hours later, the patient gave birth in her car on the way to Starr Regional Medical Center Athens.  The ED failed to reevaluate the origin of the patient’s pain after it was confirmed that she was pregnant: she could have had an ectopic pregnancy or other pregnancy related complication. Read more about this case.


TriStar Greenview Regional Hospital in Kentucky pays $90,000 to settle OIG allegations of an EMTALA violation.  The patient presented to the ED with a chief complaint of abdominal pain. The patient was 8-weeks pregnant. An ultrasound revealed a ruptured ectopic pregnancy. The patient was also hypotensive. The ED physician called TriStar Greenview’s on-call gynecologist, who refused to treat this patient’s emergency medical condition, stating that she was not their patient. The on-call gynecologist directed the ED physician to transfer her to another hospital for treatment. Read more about this case.


UNC Health Chatham Hospital, North Carolina pays $49,000 to settle OIG allegations of violating EMTALA.  The investigation revealed prior to when the patient presented to the Chatham ED via emergency medical services (EMS), the ED stated there was no cardiologist available and could not manage the patient. EMS left the ED without the patient receiving the required EMTALA medical screening exam.  Read more about this case.


Hill Hospital in Alabama entered into a $20,000 agreement with the OIG to resolve allegations that they failed to provide an appropriate medical screening examination, stabilizing treatment, and transfer for a patient presented in the ED.  The patient, who had Down Syndrome, presented with a complaint of altered mental status and was described as non-communicative and not alert. An ED physician approached the patient and her family and recommended that they seek treatment elsewhere because Hill Hospital was unable to treat her. The ED physician escorted the patient and her family out of the ED to their private vehicle. The patient was transported by wheelchair to the vehicle and was placed in the backseat of the vehicle facedown. The ED physician did not examine or treat the patient and did not make arrangements for her transfer to another facility. Read more about this case.


Learn more about EMTALA Compliance Basics online.

$30 Million Medicare Fraud Scheme

Guilty of Paying Illegal Kickbacks and Bribes

Clear Choice Diagnostics’ figurehead owner Robert M. Clark, pleaded guilty on March 26, 2024 for his part in a Medicare billing fraud scheme involving genetic tests and COVID test kits.  Medicare Beneficiary Identification numbers were purchased without lawful authority and used to bill Medicare for over-the-counter COVID-19 test kits. Clark and his co-conspirators also paid illegal kickbacks and bribes to marketers in exchange for referrals of Medicare beneficiaries for genetic tests. In total, Clark and his co-conspirators caused Clear Choice to submit approximately $30 million in fraudulent claims to Medicare for these tests, of which Medicare paid approximately $15 million.  Read more about this case.

Electronic Medical Documentation Requests

Electronic Submission of Medical Documentation System Update

The Centers for Medicare & Medicaid Services (CMS) has added information to the electronic submission of medical documentation (esMD) system.  Revisions are in red – Download the fact sheet, or go to  Change Request 11003.


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