Archive for: Billing and reimbursement
CMS warns industry about fax scam
On June 18, many providers received an alert message from CMS informing them that scammers are sending fake faxes and posing as a Medicare carrier or Medicare Administrative Contractor (MAC) in order to obtain billing information.
The agency discovered the scheme when several providers called CMS after receiving the suspicious faxes, according to Peter Ashkenaz, CMS deputy director of media affairs. The faxes asked physician staff to respond to a questionnaire and provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The faxes may have included the CMS or MAC logo.
Ashkenaz says CMS wanted to get the word out to providers immediately. “At this time, we don’t know much more than what is in the release,” Ashkenaz says.
Ashkenaz adds he could not speculate on what charges the scammer/scammers could face or what could be done with the information, but he said possession of billing information could lead to fraudulent billing of Medicare or other insurance providers.
CMS informed physicians and non-physician practitioners that they should be wary of the request and check with their contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov Web site found at www.cms.hhs.gov/MLNGenInfo/ or www.cms.hhs.gov/MedicareProviderSupEnroll.
Q&A: Billing infusion hours when there is an order to admit
Q: A patient in the ED is receiving infusion services. A physician writes an order to admit that patient as an inpatient to the regular floor. However, the patient sits in the ED for three hours waiting for a bed. Should the ED continue to bill for hours of infusion while the patient waits for a bed and as the service is provided, or does time stop when the admit order is written?
A: A patient becomes an inpatient at the time the physician writes an order for inpatient admission, regardless of whether the patient is still located in the ED. For this reason, although ED staff members continue to provide the infusion service for the patient, this service is part of the inpatient care for the patient. Providers should not bill infusion hours as an outpatient service under the outpatient prospective payment system by the ED after the time the inpatient admission order is written.
Editor’s note: Kimberly Anderwood Hoy, JD, CPC, regulatory specialist at HCPro, Inc., answered this question that appeared in the June issue of Briefings on Coding Compliance Strategies.
AHA comments on payment cuts in 2010 IPPS proposed rule
On June 15, the American Hospital Association (AHA) provided comments to CMS about changes outlined in the fiscal year (FY) 2010 IPPS proposed rule. In its comments, the agency questioned the proposed negative 1.9% documentation and coding adjustment (DCA) in FY 2010 and beyond, stating that CMS’ findings that real case mix index declined between FYs 2007 and 2008 is "incorrect and overstated." Instead, the AHA found "a historical pattern of steady annual increases of 1.2% and 1.3% in real case mix."
The proposed DCA would result in a cut in both operating and capital payments that total $23 billion over 10 years. Hospitals would be paid $1 billion less in FY 2010 than in FY 2009.
The AHA states, "Given the severity of the 1.9% proposed cut, and in light of the fact that our analysis shows real increases in patient severity, we ask that the agency significantly mitigate its proposed documentation and coding cut."
Hospitals may comment on the proposed rule until no later than June 30.
To read a more in-depth article about the AHA’s stance, visit www.healthleadersmedia.com.
Hospital Open Door Forum rescheduled
Although the next Hospital Open Door Forum was previously scheduled for June 25, CMS has confirmed that the call will be rescheduled to mid-July.
If you're looking for Hospital Open Door Forum resources, transcripts and audio recordings of past Open Door Forum conference calls are available through MedicareFind.
June 15-22 Issuances: CMS issues HITECH fact sheet, OIG audits oxaliplatin billing
CMS issues fact sheet on HITECH Act
On June 16, CMS issued a fact sheet containing information and frequently asked questions about the Health Information Technology for Economic and Clinical Health (HITECH) Act.
OIG reviews oxaliplatin billing
Last week, the OIG issued two reports on oxaliplatin billing. The OIG found that University Medical Center of Southern Nevada and Louisiana State University Health Sciences Center both billed for an incorrect number of units for this drug and, as a result, received overpayments.
View the OIG report on University Medical Center.
View the OIG report on Louisiana State University Health Sciences Center.
Manual changes related to condition code 44
By Kimberly Anderwood Hoy, HCPro's director of Medicare and compliance
I’d like to turn my attention to the manual changes related to condition code 44, as promised. Overall, the changes were designed to incorporate discussion and FAQs that were previously published in MLN Matters Article SE0622. In this respect, the changes to the manual have very few surprises. Almost everything added came directly from SE0622 and nothing added was really anything new. With that said, however, I do think that hospital case managers and anyone involved in condition code 44 cases or billing for cases with changed status should review the changes carefully to be sure they follow all the guidance provided.
One of the disappointing things about the changes is that they did not address the issue of whether the period of time from the inpatient order up to the time the patient is changed to outpatient and the observation order is written can be billed as observation time. The language stating that the entire episode of care should be billed as outpatient remains unchanged and nothing was added to clarify it. However, if we carefully consider the other changes made to the observation sections, I think we can discern that CMS does not mean for these hours of care to be billed as observation.
Read the rest of this post, or share your thoughts on this topic.
Never Events - CMS issues surgical error NCDs and related guidance
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc
In 2002, the National Quality Forum (NQF) published a list of 27 events identified as “serious, largely preventable and of concern to both the public and health care providers.” These events have become more popularly known as “never events”—events that should never occur in a well-run health care facility with appropriate quality controls.
Go to the MedicareMentor blog to read the rest of this week's note.
Double-billing settlement highlights whistleblower concerns
Earlier this week, the University of Medicine and Dentistry of New Jersey agreed to pay the federal government $2 million to settle a whistleblower lawsuit alleging that it bilked Medicaid in a double-billing scheme that started in 1993 and ended in 2003, according to the Department of Justice (DOJ).
The settlement marks the second time UMDNJ paid the government for the double-billing scheme. The first was in 2005 when the hospital paid $4.9 million to the state of New Jersey to settle criminal charges.
In the end, UMDNJ ended up paying nearly $7 million total for the scheme, but, according to Marcella Auerbach, managing partner at Nolan & Auerbach, the hospital could have avoided the lengthy and costly litigation and saved millions, if it had acted differently.
According to Auerbach, a former federal prosecutor who now exclusively represents whistleblowers in healthcare fraud cases, UMDNJ’s in-house attorney discovered the hospital and its physicians were billing for the same services back in 2001—before any whistle was blown. The lawyer brought the issue to the hospital’s attention, but the management looked the other way, and continued to double-bill for the three years following the warning, he says.
The fact that UMDNJ knew about the double-billing, knew it was illegal, and continued to do it, is what makes the case so interesting. The hospital could have saved millions if it ceased double-billing and came clean to the government through a self-disclosure, Auerbach says.
“It’s a bet,” Auerbach says. “They are betting on the fact they won’t get caught.”
However, UMDNJ hit one too many times and ended up going bust. Steven Simring, MD, the man who filed the whistleblower lawsuit will collect $801,000 for his efforts.
Based on the details of the case, Auerbach was not surprised to see a doctor blow the whistle on the hospital. Evidence shows that there were many discussions about the double-billing in which doctors expressed concern. Auerbach says it comes as no surprise that Simring would come forward and blow the whistle rather than risk prosecution.
Auerbach says the gambler’s mind-set is common in whistleblower cases. Rather than play by the rules and fess up, many facilities try to sweep problems under the rug and pretend they never happened. Some even go one step further. Auerbach says many times concerned employees will raise compliance concern only to be handed a pink slip for their trouble, which raises another legal problem.
“These people are fired for bringing points up,” Auerbach says, “Then they come to us and they have two claims.”
Auerbach says this case can be seen as a message to healthcare leaders. The DOJ is saying take any compliance concerns presented by employees or legal council very seriously and, when appropriate, self-disclose. The alternative is a lengthy, expensive, public whistleblower case.
