Healthcare Compliance


Today's healthcare regulatory environment necessitates strong and effective compliance programs. The Centers for Medicare & Medicaid Services (CMS) aggressively enforces compliance with various Medicare rules and regulations, as do the states in enforcing Medicaid rules and regulations. Over the past few years, CMS has charged several Medicare health and drug plan sponsors with compliance violations and ordered them to suspend marketing to, and enrollment of, new plan members. CMS has threatened to impose additional penalties, ranging from fines to contract termination, on plan sponsors that fail to implement corrective actions to address those violations. Likewise, the states have targeted Medicaid plans that have failed to adhere to medical loss ratio requirements, vigorously enforced prompt-payment laws, ratcheted up their efforts to ferret out fraud, waste and abuse, and assiduously monitored member service levels.

CMS mandates that Medicare and Medicaid plan sponsors adopt and periodically review compliance programs that include measures to prevent, detect and correct non-compliance with CMS program requirements and fraud, waste and abuse.

Day Pitney has formed a multidisciplinary team of lawyers, the Healthcare Compliance practice group, to work closely with in-house counsel and compliance professionals to identify, assess, and ameliorate healthcare legal and regulatory compliance risks. Our team conducts compliance risk assessments to identify and address critical compliance threats involving, for example, sales and marketing practices, network issues, appeals and grievances, product development, claims payment, pharmacy protocols, privacy protection and fraud, waste and abuse incidents. When risks are detected, we work closely with our clients to evaluate current compliance programs and design new ones to improve the quality and effectiveness of compliance controls. Given recent CMS and state compliance-related activities and an ever-changing (and more regulated) healthcare industry, it is critical that you review and update your compliance program. Day Pitney's experience in this area can help you effectively manage your healthcare legal and regulatory compliance risks.