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Regulatory MonitoringArchive for Medicare compliance
OIG issues report on high-dollar claims
On August 26, the OIG issued a report on high-dollar claims paid by CareFirst of Maryland, previously a Medicare fiscal intermediary. The OIG found that, between January 1, 2003, and September 30, 2005, CareFirst overpaid $1.2 million for 24 high-dollar payments it made for hospital outpatient claims in Maryland and the District of Columbia.
CMS reminds contractors of annual HCPCS update
On September 4, CMS issued a transmittal to remind contractors of the annual HCPCS update.
Effective date: January 1, 2010
Implementation date: January 4, 2010
CMS instructs on HIPAA 5010 implementation for the 835
On September 4, CMS issued a transmittal instructing contractors on implementation of version 5010 of the 835.
The Office of Inspector General (OIG) will be searching for relevant information prudent to your hospital’s audit. This information is called evidence. To support your audit begin to collect four types of evidence before the OIG visits:
- Physical Evidence: Paraphernalia obtained through direct inspection of property, events, and people. (e.g., maps, photographs, illustrations, written summaries of observations, charts)
- Documentary Evidence: Created evidence including: spreadsheets, accounting records, contracts, invoices, letters, performance reports, and surveys.
- Testimonial Evidence: Information received through bias-free interviews and inquiries from individuals involved in the particular audit.
- Analytical Evidence: Collect analytical evidence through the verification of amassed information, facts, and data. Laws, legal and non-legal opinions, hospital standards, and past and present operations should all be compared to your analytical findings.
This week’s tip was adapted from The Healthcare Auditor’s Handbook, for more information about the book or to order your copy click here.
By Judith Kares, an regulatory specialist for HCPro, Inc.
On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.
As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover the services provided in the inpatient setting.
Pharmaceutical giant Pfizer Inc. and its subsidiary Pharmacia & Upjohn Company Inc. will pay $2.3 million for the largest healthcare fraud settlement in the history of the Department of Justice (DOJ). According to a DOJ press release, Pfizer has agreed to pay a fee of $2.3 billion to amend criminal and civil liabilities arising from the illegal promotion of four medications – Bextra, an anti-inflammatory drug; Geodon, an anti-psychotic drug; Zyvox, an antibiotic; and Lyrica, an anti-epileptic drug.
Pfizer submitted false claims about the prescriptions to government healthcare programs that were either not accepted or covered. The provisions of the FDA state that a company must specify the intended uses of a product and products may not be marketed for any non-listed uses.
Six whistleblowers spurred the investigation by filing lawsuits under the qui tam provisions of the False Claims Act and will receive compensation totaling more than $102 million. Part of the $2.3 billion settlement will resolve allegations that Pfizer supplied kickbacks to healthcare providers to persuade them to prescribe these drugs.
The individual criminal fine of $1.195 billion is the greatest criminal fine ever procured in the United States for any matter. Kathleen Sebelius, Secretary of the Department of Health and Human Services estimates that nearly $1 billion will be allocated to Medicare, Medicaid, and other government insurance programs.
CMS released several MLN Matters articles related to transmittals previously outlined in Medicare Weekly Update.
- Addition/Deletion of HCPCS Codes – October 2009 Quarterly Update (MM6594)
- October 2009 Integrated Outpatient Code Editor (I/OCE) Specifications Version 10.3 (MM6618)
- October 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) (MM6626)
- Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for Fiscal Year (FY) 2010 (MM6607)
- October 2009 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM6585)
- Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens (MM6524)
CMS also released a special edition MLN Matters article:
- Billing for the Administration of the Influenza A (H1N1) Virus Vaccine (SE0920)
Join MedicareFind today for a direct link to these and all the documents in our regulatory database.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc
CMS recently issued Medicare Claims Processing Manual Transmittal 1799 (CR 6570), which is a Recurring Update Notification to inform contractors of new waived tests approved by the Food and Drug Administration under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Since these tests are marketed immediately after approval, CMS must notify its contractors of the new tests so that the contractors can accurately process claims. This seems like a good time to review the basic guidelines set out under CLIA with respect to waived tests.
Please accept this invitation to obtain a FREE on-demand webcast of our recent MedicareFind demonstration, Researching Regulatory Changes with MedicareFind: Find Information You Need Now.
During the webcast, you'll learn how to use MedicareFind to FIND rules and regulations for a few of today’s hot-topic areas:
- Observation: You’ll FIND recent rule changes you need to understand how to count observation time
- Physician supervision: You’ll FIND out what CMS has been saying about physician supervision under the hospital “incident-to” benefit
- Hospital-acquired conditions (HAC): You’ll FIND out how to charge for HAC-related services
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