NEWS AND PUBLICATIONS

The NYS Office of the Medicaid Inspector General ("OMIG") has dramatically increased enforcement activity in connection with Medicaid provider compliance programs: OMIG is notifying providers that their compliance programs are being placed under review. Providers should take immediate action to avoid the prospect of serious sanctions, including but...

On October 24, 2018, the President signed a new bill aimed at combating the opioid addiction epidemic that is sweeping the nation - the SUPPORT Act of 2018 .  The full Congressional summary of the the SUPPORT Act is available here . The SUPPORT Act will have a far-reaching impact on all healthcare providers and establish ma...

It is a familiar story - a pharmacy provider receives a PBM termination notice or audit findings, believes that nothing can be done, and gives up the fight.  Providers often fall into the trap of accepting PBM's narratives and not having a different perspective on what has taken place or what can be done to remedy the situation.  Whe...

A New Jersey owner of several pharmacies was charged by indictment and arraigned today on charges of conspiracy to defraud the IRS by engaging in a "cash skimming" scheme.  The indictment alleges that the pharmacy's owner, his relative, and the pharmacist co-owner conspired to conceal cash income of pharmacies and did not report...

Third-party audits have the potential to wreak havoc on independent pharmacies.An audit on its own can be extremely costly due to time dedicated to gathering necessary documents and assisting the auditor.  Further, any discrepancies found can be subject to adjustments of thousands of dollars. Suspected misconduct has recently led to refer...

The number of Medicare appeals cases pending to be heard by administrative law judges has been growing exponentially.  The backlog is now almost ten times larger than it was five years ago and is projected to reach two million by 2020 if no change is made.  The appeals process, as of now, takes at least three to four years, duri...

In a ground-shaking two weeks, the Antitrust Division of the U.S. Department of Justice approved multiple PBM/insurer mergers: first, the merger of Express Scripts Inc. and Cigna, and now, the merger of CVS Health (formerly CVS Caremark) and Aetna.  Both mergers marked major milestones. ESI was the last standalone major PBM, while the CVS...

This is the time for independent pharmacies to be actively preparing for the impact of the Cigna-ESI merger—and the ensuing Aetna-Caremark merger—if they have not already done so. The Antitrust Division of the U.S. Department of Justice has approved the proposed Cigna-Express Scripts merger, clearing a significant obstacle to Cigna's acquisition of...

Recently, HHS reiterated that severe consequences can be imposed for HIPAA violations, regardless of whether a business is still operational. If HIPAA violations were committed, a business can be charged long after its doors close. Moreover, providers working with associates who shut down operations or went bankrupt are equally liable for HIPAA vio...

CMS has released a list of updated final adverse actions that need to be reported to CMS in a timely fashion. The list includes, but is not limited to, certain convictions, exclusions, and revocations, regardless of whether records are expunged.  Additionally, CMS revoked certain requirements of Medicare enrollment in an effort to reduce provi...

2006 was a monumental year for New York physical therapists – New York State passed a law permitting physical therapists to directly treat patients without a referral from a physician, triggering an explosion of private physical therapy practices. Over a decade later, private practice is still thriving in the industry.  As patient volume ...

OIG calls for "further scrutiny" of pharmacies and prescribers in connection with compounded drugs billed to Medicare Part D.   Pharmacies must be prepared to aggressively defend against this latest attack on the independent retail pharmacy industry. An explosive new report calls for "further scrutiny" of hundreds of pharmacies and prescr...

It is of utmost importance that Medicaid providers take prompt measures when under audit to avoid such consequences. Recently, the New York Court of Appeals upheld a recoupment of funds by the NYS Office of the Medicaid Inspector General ("OMIG") against a provider, rejecting the provider's claim that it was not sufficiently notified of the recoupm...

A doctor's certification or medical judgment regarding a certain treatment can be considered "false" if the treatment is not considered "reasonable and necessary" under the government's definition, even if the terms are not defined for the specific medical treatment. In a recent decision, United States ex rel. Polukoff v. St. Mark's Hospital ,...

In a sweeping crackdown that vastly exceeded investigations of years' past, the U.S. Department of Justice and Medicare Fraud Strike Force charged 601 individuals with over $2 billion in healthcare fraud. In Brooklyn and Long Island alone, numerous healthcare providers were charged with over a combined $163 million in healthcare fraud. The Medicare...

New Jersey providers should be alert to the recently signed into law Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act.The Act pertains to, and enhances, consumer protections related to out-of-network healthcare charges.Health care facilities and professionals must ensure their compliance with these new requ...

The recently passed New York State budget bill including sweeping new protections for independent pharmacies facing PBM audits.  The bill, which amends the Public Health Law, requires PBMs, when conducting audits, to accept purchase invoices from a broader range of wholesalers and distributors.  This provision is notable as PBMs...

The former NYC Earned Sick Time Act, popularly known as the Paid Leave Law, is now the Earned Safe and Sick Time Act.  Previously, the Act obligated employers to provide a certain amount of sick leave for their employees. The new amendments to the Act, which are presently going into effect, allow employees to use paid leave not only for s...

Recently, New York State implemented a two-year moratorium on the processing and approval of applications for licensure of Licensed Home Care Service Agencies ("LHCSAs").This moratorium suspends the Department of Health's processing of LHCSA applications, subject to certain exceptions. Presently, the exceptions include applications for ALP-Related ...

Healthcare providers are increasingly feeling the cost of employing excluded individuals.Indeed, over the past year, the number of enforcement actions taken against physician's offices, pharmacies and other entities employing excluded individuals have risen sharply. "Excluded individuals" are parties excluded from Federally-funded healthcare progra...