The U.S. Department of Health and Human Services, Office of Inspector General (OIG) recently released its Semiannual Report (SAR) covering the period October 1, 2024 to March 31, 2025. The SAR is a must-read because it identifies a wide array of risk areas, which will undoubtedly help providers modify their own risk assessments and audit work plans to stay ahead of government regulators in the ongoing fight against fraud, waste, and abuse.
The U.S. Department of Justice, Criminal Division (DOJ) recently and unexpectedly announced changes to the manner in which it handles criminal investigations and prosecutions of white-collar and corporate cases. These changes are aimed at clarifying DOJ’s criminal enforcement priorities, increasing the efficiency with which cases are investigated and resolved, and emphasizing the benefits of voluntarily self-disclosing potential misconduct. They also signal a more business-friendly approach than in the past, and will be undoubtedly welcomed by corporations and executives alike.
On May 21, 2025, Centers for Medicare & Medicaid Services (CMS) announced it will immediately expand its audits of Medicare Advantage (MA) plans to verify that the MA plans only submit accurate diagnoses for its enrollees. Although CMS directs these audits toward the MA plans, they inevitably impact providers.
This month, the New York Department of Health (DOH) published a Material Transactions Notice Form for “heath care entities” to report “material transactions” to DOH.
On May 14, 2025, Judge Michael P. Shea of the Connecticut District Court soundly rejected the Texas NSA decision, and held that “the NSA creates a private cause of action to enforce IDR awards.”