2 ms·
> Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a
by tbrownaw 2y ago
> Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.
Sounds like the "what" is already properly illegal without needing to dictate the "how".
- lotsofpulp 2y agoYes, the root problem is CMS effectively audits managed care organizations (MCO, or health insurance companies) far too rarely. And even when they do audit them, they audit far too few and with insufficient depth such that people working inside the MCO have no justification to spend more resources on ensuring the job is done properly. If CMS was constantly auditing random cases, then the MCOs would have to tighten up operations. As it is, any MCO that does will lose out to any MCO that plays it fast and loose, since MCO profit margins are low single digit percentages. Although, I am sure one can kick up the problem to legislators not allocating enough funding to CMS to constantly audit MCOs, just like the IRS does not have enough funding to audit sufficient taxpayers.