Archive for: September, 2008
CMS Transmittals and MLN Matters articles
CMS issues MLN Matters articles
CMS released two MLN Matters articles last week related to transmittals previously announced in Medicare Weekly Update.
- October 2008 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 14.3, Effective October 1, 2008
CMS Regulations
CMS publishes final rule on termination of non-random prepayment complex medical review
On September 26, CMS published in the Federal Register a final rule setting forth the criteria CMS contractors will use for terminating a provider or supplier from non-random prepayment complex medical review. CMS issued the final rule pursuant to statutory requirements in the Medicare Prescription Drug, Improvement and Modernization Act of 2003.
View the final rule.
News: Jury convicts Los Angeles DME provider of Medicare fraud
A federal jury found Leonard Uchenna Nwafor, owner and operator of Pacific City Group Inc., a Los Angeles-based durable medical equipment (DME) company, guilty of conspiracy of healthcare fraud and healthcare fraud, according to a Department of Justice (DOJ) press release.
Nwafor submitted over a $1 million worth of claims for medically unnecessary motorized wheelchairs and accessories. He received over $500,000 from Medicare for those claims. One blind beneficiary told the jury he received a wheelchair that he obviously could not operate.
Los Angeles area physicians, whose names appeared on the prescriptions for the wheelchairs, testified the prescriptions were forged. They also said the prescriptions were written for patients they had never seen and were for conditions outside their areas of expertise.
Nwafor will be sentenced on December 1.
To read the DOJ press release, click here
News: Medicare announces 2009 deductibles, premiums
CMS announced last week that the 2009 monthly premium for Medicare Part B will stay at $96.40, the same as it was in 2008. It’s the first year since 2000 there was no increase in the standard premium from the previous year.
According to CMS, the standard Medicare Part B premium is set to cover one-fourth of the average cost of medical services incurred by beneficiaries over age 65. Even though medical expenses for the beneficiaries are expected to increase in 2009, the premium was not increased because the Supplementary Medical Insurance trust fund, from which the Part B expenditures are drawn, is expected to be at a higher than adequate level at the end of 2008.
In contrast, Part A beneficiaries will see a jump in costs. While 99% of them do not pay a monthly premium, the cost of the Part A deductible will rise $44 for 2009, from $1,024 to $1,068. The deductible covers up to 60 days of Medicare-covered inpatient hospital care within a benefit period. After 60 days in 2009, Part A beneficiaries must pay an additional $267 per day for days 61-90, and $534 per day for more than 90 days. These costs are up from the prices in 2008, which were $256 and $512, respectively.
Source: Centers for Medicare & Medicaid Services
Federal judge dismisses $15M false claims case
A federal judge recently granted a summary for dismissal in the case that alleged East Texas Medical Center Regional Healthcare System of submitting false claims to Medicaid, according to the legal journal The Southeast Texas Record.
The lawsuit alleged East Texas Medical Center (ETMC) Athens, located in Athens TX, illegally submitted claims for additional reimbursement under the intergovernmental transfer program which applies to public rural hospital.
The judge decided ETMC is a private hospital and should not have received additional reimbursement from the intergovernmental transfers, but the Texas Organization of Rural and Community Hospitals (TORCH) told ETMC it was qualified. Because ETMC relied on the advice it received from TORCH, the judge decided ETMC did not knowingly submit a false claim and therefore cannot be in violation of the False Claims Act.
To read The Southeast Texas Record article click here.
September 12-19 CMS Transmittals and MLN Matters articles
CMS issues quarterly update to National Correct Coding Initiative (NCCI) edits
On September 19, CMS released the fourth quarter update to the NCCI edits.
Effective date: October 1, 2008
Implementation date: October 6, 2008
View the transmittal.
CMS issues quarterly hospital Outpatient Prospective Payment System (OPPS) update
On September 19, 2008, CMS issued the fourth quarter OPPS update.
Effective date: October 1, 2008
Implementation date: October 6, 2008
View the transmittal.
CMS issues transmittal on reporting National Provider Identifiers (NPI) for secondary providers
On September 12, CMS released a transmittal clarifying instructions for reporting secondary providers’ NPIs on paper and electronic claims.
Effective date: May 23, 2008
Implementation date: September 26, 2008
View the transmittal.
View a related MLN Matters article.
CMS updates waived tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA)
On September 12, CMS issued a transmittal regarding new waived tests under CLIA.
Effective date: October 1, 2008
Implementation date: October 6, 2008
View the transmittal.
View a related MLN Matters article.
CMS releases MLN Matters articles
CMS released three MLN Matters articles last week related to transmittals previously announced in Medicare Weekly Update.
- Payment for Implanted Prosthetic Devices for Medicare Part B Inpatients
- Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments
- October 2008 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Tip: Quality of Care
Quality of care continues to be a priority with both the state and federal government. Consider the following questions and concerns when examining your compliance program:
- Evaluate the procedure in place to monitor quality of care.
- Is an oversight board in place?
- Is the quality of care part of the provider’s plan?
- How are quality-of-care problems handled?
- Educate professional and nonprofessional staff on quality of care and the ethical responsibility each has in this area.
- Is quality of care in the mission statement?
- Are the goals and charitable duties of the facility in concert with quality of care?
- Immediately address problems or concerns regarding quality of care and errors.
- Is there a clear line of communication among staff, the compliance officer, and the board to address quality of care problems?
- Are inquiries and questions handled discretely and in confidence?
- Are inquiry results made available to the complainant and others in a timely manner?
-
Conduct internal audits and evaluations to ensure quality of care in all areas of the facility.
-
Make them part of compliance.
-
Use quality of care to your advantage.
-
Recognize and promote the organization’s effectiveness and efficiency to the government and, more importantly, to the public.
-
Quality of care, correction of errors, and promotion of good healthcare systems will drive down the cost of malpractice insurance and give beneficiaries the services and care they need.
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here
Staten Island University Hospital to pay $89 million to settle fraud claims
- Is an oversight board in place?
- Is the quality of care part of the provider’s plan?
- How are quality-of-care problems handled?
- Is quality of care in the mission statement?
- Are the goals and charitable duties of the facility in concert with quality of care?
- Is there a clear line of communication among staff, the compliance officer, and the board to address quality of care problems?
- Are inquiries and questions handled discretely and in confidence?
- Are inquiry results made available to the complainant and others in a timely manner?
-
Make them part of compliance.
-
Recognize and promote the organization’s effectiveness and efficiency to the government and, more importantly, to the public.
-
Quality of care, correction of errors, and promotion of good healthcare systems will drive down the cost of malpractice insurance and give beneficiaries the services and care they need.
Staten Island University Hospital (SIUH) agreed to pay almost $89 million to settle four separate charges for alleged defrauded Medicare, according to a Department of Justice (DOJ) press release.
The DOJ alleges SIUH:
-
Fraudulently billed Medicaid and Medicare for inpatient alcohol and substance abuse detoxification treatment
-
Used incorrect billing codes for cancer treatment performed at the hospital to receive reimbursement for services not covered by Medicare
-
Deliberately inflated the resident count from the 1996 cost report year through the 2003 cost report year
-
Billed Medicare and Medicaid for treatment of psychiatric patients in unlicensed beds between July 2003 and September 2005
Whistleblowers filed two of the four counts.
Dr. Miguel Tirado, a former SIUH Director of Chemical Dependency Services, alleged SIUH performed alcohol and substance abuse in unauthorized beds. SIUH will pay the $11.8 million to the federal government and $14.9 million to the state of New York, according to an agreement. Tirado will receive $2.3 million from the federal government for filing the suit.
Elizabeth M. Ryan, widow of an SIUH cancer patient, alleged the hospital used incorrect codes to bill for outpatient cancer treatments. SIUH will pay the $25 million to settle this claim, and Ryan will receive $3.75 million of it.
The government filed the other two claims. According to the agreement, SIUH will pay the government $35.7 million for inflating cost report numbers and $1.5 million for allegedly performing psychiatric treatments in unlicensed beds.
To read the full DOJ press release click here.
