Archive for August, 2008
Correction to the Provider Reimbursement Determinations and Appeals final rule published in Federal Register
On August 21, CMS published in the Federal Register a correction to the previously published Provider Reimbursement Determinations and Appeals final rule. As reported in the May 27 issue of Medicare Weekly Update, the final rule updates, clarifies, and revises various provisions of the regulations governing provider reimbursement determination, appeals before the Provider Reimbursement Review Board, appeals before the intermediaries, and administrator review of decisions made by the Board.
Fiscal year (FY) 2009 hospital Inpatient Prospective Payment System (IPPS) final rule published in Federal Register
On August 19, CMS published the FY 2009 IPPS final rule in the Federal Register. The display copy of the final rule had previously been published on the CMS Web site, as reported in the August 5 issue of Medicare Weekly Update.
Elderly patients with chronic conditions face a tough choice after their total Medicare drug spending has exceeded $2,400. They must either pay for their medications out of pocket or stop taking them.
Medicare drug benefits do not kick in again until patients have spent more than $3,850. And in 2007, about 15% of the 3.4 million Medicare beneficiaries who hit this drug coverage gap, known as the doughnut hole, quit taking their medications. The percentage of patients who stopped taking their medications varied by condition. For example, about 8% of patients stopped taking medications for Alzheimer’s disease, while 20% stopped taking medications for acid reflux disease.
The doughnut hole program was put into place by Congress in 2003 as a way to cut spending. Many lawmakers and analysts say improvements can be made to the program and look to a newly elected president and Congress to make those decisions.
Sources: Health Leaders Media, Yahoo! News
You have more time to teach your patient access staff members about the revised Advance Beneficiary Notice of Noncoverage (ABN) form.
CMS pushed back the mandatory date for using the new form from September 1, 2008 to March 1, 2009.
Providers may still use the revised ABN for all situations in which Medicare payment is expected to be denied. The revised ABN, CMS says, replaces the existing ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007).
Beginning March 1, 2009, the ABN-G and ABN-L will no longer be valid. According to CMS, key features of the form include:
- A new official title, the “Advance Beneficiary Notice of Noncoverage (ABN),” to more clearly convey the purpose of the notice;
- A mandatory field for cost estimates of the items/services at issue; and
- A new beneficiary option, under which an individual may choose to receive an item or service and pay for it out-of-pocket, rather than have a claim submitted to Medicare.
Uninsured Americans will leave an unpaid tab of $56 billion for healthcare this year, according to a recent study done by George Mason University in Fairfax, VA, and the Urban Institute think tank in Washington, DC.
These costs will be covered mostly by the government. A smaller portion, $30 billion, will be paid by the uninsured population out of pocket. The study also predicts that the uninsured would have used $122.6 billion more for healthcare services—for a total of $208.6 billion—if they had been insured. People with insurance normally use more healthcare services, according to the study.
Last year, healthcare spending accounted for $2.2 trillion, or 16.3% of the gross domestic product. Federal figures show that amount could double during the next 10 years, and could become more of the government’s responsibility, despite new programs to cut its costs.
Source: The Wall Street Journal
Medicare allegedly instructed outside auditors ignore government policies designed to accurately report fraud and as a result, the agency’s claim of preventing millions of dollars in fraud in 2006 are misleading, according to an OIG audit.
The OIG said one-third of spending for wheelchairs, oxygen supplies, and other medical equipment for fiscal year 2006 was improper. The report estimates the fraud totaled approximately $2.8 billion. In its report to Congress, CMS said it reduced the amount of durable medical equipment (DME) fraud in FY 2006 to $700 million.
CMS hired AdvanceMed, a subsidiary of Computer Sciences Corporation, to audit Medicare DME spending. According to the OIG report, CMS officials told AdvanceMed to ignore Comprehensive Error Rate Testing program, an auditing protocol required by law. Instead of randomly selecting and comparing invoices to physicians’ records, auditors were allegedly instructed to only examine the invoices from DME suppliers.
Medicare introduced a competitive bidding program to help control costs and decrease fraud. Congress suspended the program, that was originally effective July 1.
To read the OIG audit click here
On August 22, a grand jury indicted Dr. James Ellegood, his wife Wynsleen Ellegood, and Dr. Rajitha Goli for submitting false claims to Medicare and Medicaid for non-rendered physician home visits.
The Ellegoods operate Missouri Physician Home Services, Inc. based in Desoto, MS. Goli provided medical services to the company’s patients.
According to the Department of Justice (DOJ) press release, nurses and nurse practitioners employed by PHS made unaccompanied home visits to patients. Dr. Ellegood would later sign claims stating he was present at the visit when he was not. According to the DOJ, Ellegood signed off on visits that occurred while he was as far away as the Bahamas and Mexico.
The DOJ also claims PHS submitted claims using Ellegood’s identifier number for services provided by Goli knowing that she was not allowed to practice in the state and has been excluded from the Medicare and Medicaid programs. In 2002, Goli was convicted of healthcare fraud resulting in the revocation of her medical license.
An internal investigation obviously requires you to interview the subject of the complaint. However, in many cases other employees may have helpful information, too. However, staff members on the receiving end of an investigational interview may have the following concerns:
- Fear they have unknowingly done something wrong and will lose their job
- Concern they may implicate a coworker and be responsible if he/she loses his/her job.
- Fear of being viewed as being disloyal or a “rat” by other employees
- Concern about working with an accused employee who is later found not to have done anything wrong
- Concern about being sued by an accused employee for defamation
Each of these concerns stands in the way of obtaining information you need. However, it is the employee’s duty to the organization to disclose and information he or she may have about potential noncompliance. Remind employees about this duty; explain that by assisting with the investigation, they are doing the right thing, for the right reasons.
Don’t be afraid to directly attack the notion of someone being a “rat.” Describe how the organization investigates matters, not due to someone’s personal vendetta, but to protect the integrity of the company, its employees, and its patients.
Explain the organization’s duty to its patients by ensuring that employees act with integrity. By helping with the investigation, the employee helps to protect the organization and its patients.
This tip was adapted from the Internal Investigations Handbook.
For more information about the book or to order your copy, click here.
Training Programs
Audits & Assessments
Regulatory Monitoring
Get blog updates in your e-mail
Subscribe to our free RAC Report e-zine
