Medicare and Medicaid billing is governed by complex federal and state regulations that require strict compliance to avoid fraud allegations, overpayment demands, and exclusion from government programs. Noncompliance can result in severe civil and criminal penalties, including False Claims Act (FCA) violations, recoupments, and potential prosecution. This course provides an in-depth legal analysis of Medicare and Medicaid billing laws, common compliance challenges, fraud enforcement trends, and best practices for avoiding liability.
Students will gain expertise in billing compliance, federal oversight mechanisms, audit defense, appeals procedures, and regulatory risk management to help healthcare providers and organizations adhere to federal and state laws while mitigating liability risks.
Course Objectives
By the end of this course, students will:
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Understand the Legal and Regulatory Framework Governing Medicare and Medicaid Billing – Analyze CMS regulations, Stark Law, the Anti-Kickback Statute, and False Claims Act implications.
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Evaluate Proper Billing and Coding Practices to Ensure Compliance – Learn how to bill accurately, avoid upcoding and unbundling, and ensure proper documentation.
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Examine the Role of CMS, OIG, and DOJ in Enforcing Billing Compliance – Study how federal agencies conduct audits, investigations, and fraud enforcement actions.
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Analyze Case Law on Fraudulent Billing and Compliance Failures – Review legal precedents and government settlements involving billing violations.
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Assess the Risks of Overpayments, Claim Denials, and Appeals Procedures – Learn how to respond to claim rejections, overpayment demands, and audits.
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Identify Best Practices for Internal Compliance Programs and Self-Audits – Develop protocols to proactively prevent billing errors and regulatory violations.
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Explore Fraud and Abuse Laws That Impact Medicare and Medicaid Billing – Investigate how Stark Law, Anti-Kickback Statutes, and the False Claims Act affect reimbursement.
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Prepare for Future Trends and Regulatory Changes in Medicare and Medicaid Billing – Examine proposed legislation, AI-driven fraud detection, and evolving compliance challenges.
