Archive for: Medicare compliance
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.
June 8-15 Issuances: ICD-9-CM documents available
ICD-9-CM October 2009 update available
The fiscal year 2010 ICD-9-CM index to diseases addenda, tabular addenda, and new code conversion table are now available. These are effective October 1, 2009.
View the ICD-9-CM index to diseases addenda.
View the ICD-9-CM tabular addenda.
View the ICD-9-CM new code conversion table.
Frequently asked questions
CMS issued several new/updated frequently asked questions (FAQ) last week.
View a listing of recently updated FAQs.
June 8-15 Transmittals and MLN Matters articles: CMS implements NCDs for surgical never events, and more
CMS implements NCDs for surgical never events
On June 12, CMS issued updates to the Claims Processing Manual and National Coverage Determinations (NCD) Manual pertaining to its NCDs for wrong surgery on a patient, wrong site surgery, and surgery on the wrong patient.
Effective date: January 15, 2009
Implementation date: July 6, 2009, for B MACs and carriers; October 5, 2009, for A MACs, FIs, and FISS
View the transmittal to the Claims Processing Manual.
View the transmittal to the NCD Manual.
CMS issues RAC update
On June 12, CMS updated the Medicare Financial Management Manual with information pertaining to the RAC national program.
Effective date: July 13, 2009
Implementation date: July 13, 2009
CMS implements redesigned provider statistical and reimbursement system
On June 12, CMS announced that the redesigned provider statistical and reimbursement system (PS&R) system is now available. The new PS&R will be used for all cost reports ending January 31, 2009, and later. Chapter 8 of the Medicare Financial Management Manual has been updated.
Effective date: July 13, 2009
Implementation date: July 13, 2009
CMS implements new CAH requirements
On June 12, CMS implemented new critical access hospital (CAH) requirements Under 42 CFR 485.610(e) related to CAH co-location and CAH provider-based locations.
Effective date: June 12, 2009
Implementation date: June 12, 2009
CMS issues transmittal on CMS-855 enrollment applications
On June 12, CMS issued a transmittal in which it changed the time period during which certain Medicare providers and suppliers can submit Medicare enrollment applications in advance of the effective date listed thereon.
Effective date: July 13, 2009
Implementation date: July 13, 2009
CMS issues MLN Matters articles
CMS issued several MLN Matters articles related to transmittals previously outlined in Medicare Weekly Update.
- Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Rate Year 2010
- New Drug/Biological Health Care Procedure Code System (HCPCS) Codes for July 2009 Update
- New Waived Tests
MedicareFind. The Search is Over.
The Search is Over.
HCPro, Inc. has announced the launch of MedicareFind (www.medicarefind.com), a new Web-based regulatory database that allows healthcare managers to quickly locate, access, and keep up with Medicare reimbursement rules and regulations.
MedicareFind expands HCPro’s products and services that assist healthcare providers with monitoring and responding to the changing regulatory environment in which they work. The Web site features a uniquely robust, flexible, and easy-to-use search engine combined with a vast and constantly updated database of documents. Users will find the specific regulatory source authority document they need quickly instead of scrolling through pages of search results.
MedicareFind first debuted in April at The Health Care Compliance Association’s annual Compliance Institute in Las Vegas. Institute attendees stepped up to take a side-by-side challenge which pitted MedicareFind against the CMS Web site.
“MedicareFind found the right documents faster than a CMS search every time,” said Lauren McLeod, HCPro Group Publisher. “People found it easy to use and liked the filters that allowed them to narrow their search by agency, document type, and date. They told us it was easier to quickly determine whether the document met their needs because they saw all the pertinent details about the document in the search results.”
HCPro regulatory experts and developers worked with 50 development partners — professionals from healthcare organizations across the nation — throughout the development of MedicareFind. McLeod said the partners have been an integral part of the development process, from determining which rules and regulations to include in the database to testing the site design and the search features.
With shrinking workforces and limited budgets, MedicareFind was developed in response to the need for a solution that offers increased productivity and time saved searching for the regulatory compliance guidance.
MedicareFind is available to single users or as a multi-user or site license, and HCPro will offer free trials at the database Web site (www.medicarefind.com) For more information about MedicareFind, visit www.medicarefind.com.
OIG lists recommendations not fully implemented by HHS
The Department of Health and Human Services (HHS) failed to fully implement recommendations made by the Office of Inspector General (OIG), according to the OIG’s “Compendium of Unimplemented Office of Inspector General Recommendations”, released May 29.
The OIG provided the recommendations after completing various audits pertaining to healthcare fraud and abuse.
The OIG’s priority recommendations, which are explained in more detail in the document itself, include:
- Modify payment policy for Medicare hospital bad debts (estimated savings $340 million)
- Reduce the rental period for Medicare home oxygen equipment (estimated savings $3.2 billion)
- Modify payments to managed care organizations (estimated savings $1.97 billion)
- Extend additional rebate payment provision to generic drugs (estimated savings $966 million)
- Limit enhanced payments to cost and require that Medicaid payments returned by public providers be used to offset the federal share (estimated savings $120 million)
- Ensure Medicaid reimbursement for brand-name and generic drugs accurately reflects pharmacy acquisition costs (estimated savings $1.08 billion for brand-name drugs and TBD for generic drugs)
